epidemiological report no. 12-hf-97hrf1a-10 … · ms tanya harvin, occupational health nursing...

EPIDEMIOLOGICAL REPORT NO. 12-HF-97HRF1A-10

PROSPECTIVE INVESTIGATION OF INJURY RATES

AND INJURY RISK FACTORS AMONG

FEDERAL BUREAU OF INVESTIGATION

NEW AGENT TRAINEES,

QUANTICO VIRGINIA, 2009-2010

Approved for Public Release, Distribution Unlimited

ACKNOWLEDGEMENTS

We would like to thank Dr. James Yoder (FBI Health Care Program Unit) who worked

assiduously to develop the interagency agreement, coordinate our efforts within the FBI

Academy, and kept the project active by handling problems as they arose. Ms Tanya Harvin,

Occupational Health Nursing Supervisor, provided outstanding and tireless efforts in

coordinating our visits to the FBI Academy, obtaining our security passes, providing medical

information on the new agent trainees, and in answering our many questions on medical

treatment of new agent trainees. Special Agent Timothy Burke, Training Director, coordinated

our visits within the training division, provided us with much of the training-related information,

and through conversation and example, provided us insights into the training of prospective

agents at the academy. Special Agent Gerald Jackson took over when Special Agent Burke left

the training division and coordinated our student briefings. Special Agents Susann Dreiling, Jay

Moeller, and Michael Vuong provided us with physical fitness test data and answered our many

questions regarding physical training, defensive tactics training, and the physical preparation of

new agent trainees. Dr. Tom Gross, Clinical Director, offered us practical knowledge of injuries

and injury mechanisms among the new agents. Ms Terry Dotson supplied us with critical

information on Workman’s Compensation Claims. Ms Tammy Schuldt made available to us

information on new agents who did not complete training. We also thank Special Agent Melinda

Casey for insights on FBI new agent training.

REPORT DOCUMENTATION PAGE

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The public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS.

1. REPORT DATE (DD-MM-YYYY)

August 2010

2. REPORT TYPE

FINAL

3. DATES COVERED (From – To)

March 2009–March 2010

4. TITLE AND SUBTITLE

Prospective Investigation of Injury Rates and Injury Risk Factors among Federal Bureau of Investigation New Agent Trainees, Quantico Virginia, 2009-2010

5a. CONTRACT NUMBER

5b. GRANT NUMBER

5c. PROGRAM ELEMENT NUMBER

6. AUTHOR(S)

Joseph J Knapik, Tyson Grier, Anita Spiess, David I Swedler,

Keith G Hauret, Bria Graham, Bruce H Jones

5d. PROJECT NUMBER

5e. TASK NUMBER

5f. WORK UNIT NUMBER

7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) US Army Public Health Command (Provisional), Aberdeen Proving Ground MD

8. PERFORMING ORGANIZATION REPORT NUMBER 12-HF-97HRF1A-10

9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES)

Federal Bureau of Investigation, Human Resources Division, Office of Medical Services, Health Care Programs Unit

10. SPONSOR/MONITOR’S ACRONYM(S)

FBI

11. SPONSOR/MONITOR’S REPORT NUMBER(S)

12. DISTRIBUTION/AVAILABILITY STATEMENT: Approved for public release; distribution is unlimited

13. SUPPLEMENTARY NOTES

14. ABSTRACT A one-year prospective examination was conducted of injury rates and injury risk factors during Federal Bureau of Investigation (FBI) new agent training. Injuries were obtained from medical records at the FBI academy and injury compensation forms. Potential injury risk factors were obtained from a lifestyle questionnaire and existing data at the FBI Academy. A total of 426 men and 105 women were involved in the project. Thirty-five percent of men and 42% of women had one or more injuries during training. The most common diagnoses were traumatic sprains (14%), traumatic strains (12%), musculoskeletal pain (12%), abrasions/lacerations (11%), and contusions (11%). The most common anatomical locations were the knee (10%), thigh (8%), shoulder (8%), eye (8%), finger (7%), face (6%), lower back (6%), and head (5%). The most common activities associated with injuries were defensive tactics (58%), physical fitness training (20%), physical fitness testing (5%), and firearms training (3%). Among the men, higher injury risk was associated with older age, slower 300-meter sprint speed, slower 1.5-mile run time, lower total points on the PFT, lower self-rated fitness, lower or higher frequency or duration of aerobic exercise, a prior upper or lower limb injury, and current foot or knee pain. Among women, higher injury risk was associated with slower 300-meter sprint speed, slower 1.5-mile run time, lower total points on the PFT, current back pain, and other factors. Initial fitness test scores of at least 12 points for men and 15 points for women were associated with the lowest injury risk in training. Recommendations for reducing injury risk include: 1) encouraging trainees to arrive at the FBI Academy with an entry level PFT score of 12 for men and 15 for women, 2) encouraging aerobic exercise 3-4 times/week, 20-30 minutes/session prior to new agent training, 3) emphasizing the association between low fitness and higher injury risk to new agent trainees and to FBI field offices, 4) continuing statistical analysis of PFT failure rates and providing these reports to field offices, 5) examining defensive tactics training to determine whether injury risk can be further reduced, 6) improving information collection on injury mechanisms by obtaining both the activity associated with the injury and the mechanism of injury, 7) using the most common injuries identified here to assist in medical planning, 8) remaining vigilant for symptoms of exertional rhabdomyolysis, and 9) continuing to investigate associations between prior injury and pain that limits activity to determine whether prophylactic measures can be put in place to further reduce injury risk in training.

15. SUBJECT TERMS: Defensive tactics, physical activity, physical fitness, physical training, menstrual history, smoking, demographics, push-ups, sit-ups, 300-meter run, 1.5-mile run, age, height, weight, body mass index, prior injury, pain, activity limitations

16. SECURITY CLASSIFICATION OF: UNCLASSIFIED

17. LIMITATION OF ABSTRACT

18. NUMBER OF PAGES

19a. NAME OF RESONSIBLE PERSON

Dr. Joseph Knapik

a. REPORT

Unclassified

b. ABSTRACT

Unclassified

c. THIS PAGE

Unclassified

19b. TELEPHONE NUMBER (include area code) 410-436-1328

Standard Form 298 (Rev.8/98) Prescribed by ANSI Std. Z39.18

Epidemiological Report No. 12-HF-97HRF1A-10, MARCH 2009-MARCH 2010

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EXECUTIVE SUMMARY

EPIDEMIOLOGICAL REPORT NO. 12-HF-97HRF1A-10

PROSPECTIVE INVESTIGATION OF INJURY RATES AND INJURY RISK FACTORS

AMONG FEDERAL BUREAU OF INVESTIGATION NEW AGENT TRAINEES,


1. INTRODUCTION AND PURPOSE. The Federal Bureau of Investigation (FBI) Human

Resources Division, Office of Medical Services, Health Care Programs Unit, requested the

assistance of the United States Army Public Health Command (USAPHC) in injury prevention

efforts at the FBI New Agent Training Program at the FBI Academy, Quantico, Virginia. An

Interagency Agreement was completed for a two phase project. Phase 1 was a retrospective

examination of available records to describe injury rates and physical fitness among new agent

trainees and to examine relationships between fitness and injuries. Phase 2 was a more

comprehensive prospective examination of injuries and injury risk factors but with fewer new

agents involved. This report details the results of Phase 2.

2. METHODS.

a. This project employed a prospective cohort design. New agents enrolled in the project

were those arriving for the 21-week FBI New Agent Training Courses conducted between March

2009 and March 2010. Shortly after arrival for the course, the men and women completed a

lifestyle questionnaire that asked about age, height, weight, tobacco use, physical activity, self-

assessed physical fitness, prior injuries and (for women) menstrual history. They also completed

a New Agent Trainee Profile that asked them about educational level, marital status, number of

children, foreign languages spoken, military experience, law enforcement experience, and

dominate hand. Standard Form 88 (SF88, Report of Medical Examination) was used to obtain

information on the new agent’s gender, height, weight, race, and date of birth.

b. Physical fitness test (PFT) data were obtained from a database in the Physical Fitness

Training Section of the FBI Academy. The PFT consisted of four scored events: push-ups to

exhaustion, 1-minute sit-ups, a 300-meter run, and a 1.5-mile run. Points were assigned to

performance levels on each PFT event; passing the test required a score of 12 with at least 1

point on each event.

c. Injury data were obtained from the Medical Data Base (MDB), where medical care

providers at the FBI Academy Health Clinic at Quantico, Virginia, routinely entered information

on medical encounters. USAPHC personnel examined each of the new agent’s medical

encounters and determined if the encounter was for an injury or for other medical care. For each

injury encounter, extracted information included the date of visit, type of visit (new injury visit

or follow-up on a previous visit), diagnosis, anatomical location, and activity associated with the


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injury. Injury information was also obtained from the United States Department of Labor’s, CA-

1 form (Federal Employee’s Notice of Traumatic Injury and Claim for Continuation of

Pay/Compensation). The CA-1 was used to enhance information regarding the activity

associated with the injury and in some cases the injury diagnosis and anatomical location. An

injury case was defined as a new agent who sustained physical damage to the body and sought

medical care or medical compensation one or more times during the period of new agent

training.

3. RESULTS.

a. A total of 426 men and 105 women were involved in this prospective project. There

were 315 new injury cases and 44 follow-up encounters. Thirty-five percent of men and 42% of

women had one or more injuries (relative risk (women/men)=1.20, 95%confidence interval

(CI)=0.93-1.55). The injury incidence rates were 2.54 and 3.22 per 1,000 person-days among the

men and women, respectively (rate ratio (women/men)=1.26, 95% CI=0.90-1.77). Overuse and

traumatic injury cases made up 14% and 68% of new injury cases, respectively. The most

common diagnoses were traumatic sprains (14%), traumatic strains (12%), musculoskeletal pain

(12%), abrasions/lacerations (11%), contusions (11%), and insect bites (11%). The most

common anatomical locations were the knee (10%), thigh (8%), shoulder (8%), eye (8%), finger

(7%), face (6%) lower back (6%), and head (5%). The most common activities associated with

injuries were defensive tactics (58%), physical fitness training (20%), physical fitness testing

(5%) and firearms training (3%).

b. Among the men, higher injury risk was associated with: older age, slower 300-meter

sprint time, slower 1.5-mile run time, fewer total points on the PFT, lower self-rated fitness,

lower or higher frequency or duration of aerobic exercise, a prior upper or lower limb injury

(especially if the injury was still limiting activity), and foot or knee pain limiting activity.

Among the women higher injury risk was associated with: slower 300-meter sprint time, slower

1.5-mile run time, fewer total points on the PFT, back pain limiting activity, and other factors.

Initial PFT scores of 12 points or higher for men and 15 points or higher for women were

associated with the lowest injury risk in training.

c. A majority of the new agents reported to the Academy with favorable lifestyle

characteristics. Only 3% of men and women had smoked a cigarette in the last two months; 6%

of men and 1% of women had used smokeless tobacco in the same period. Ninety-five percent

of men and 96% of women performed vigorous aerobic activity at least 3 days/week for at least

16-30 minutes/session in the previous two months; 77% of men and women had performed

weight training at least twice a week in the last 2 months. These activity levels are those

recommended by the American College of Sports Medicine for improving aerobic and muscle

strength fitness. High levels of aerobic training (≥5 days/week) were associated with higher

injury risk.


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4. RECOMMENDATIONS:

a. Encourage new agents to arrive at the FBI Academy in physical condition to achieve

an entry level PFT score of at least 12 for men and 15 for women. Lower scores were associated

with higher injury risk. A higher level of aerobic fitness (faster 1.5-mile run times) appears to be

of particular importance.

b. Encourage a moderate amount of aerobic exercise prior to new agent training.

Prospective data suggested that too much or too little aerobic activity was associated with higher

injury risk. Recommended frequency is 3-4 times/week for 20-30 minutes each time. Encourage

strength training twice a week.

c. Emphasize the association between low fitness and higher injury risk to new agent

trainees and to FBI field offices by providing quantitative information from both retrospective

and prospective investigations.

d. Continue statistical analysis of PFT failure rates and provide these reports to field

offices to motivate them to more adequately prepare new agents in terms of their physical fitness.

e. Examine defensive tactics training to determine if injury risk can be reduced. By far,

the largest numbers of injuries were associated with defensive tactics training in both the

retrospective and prospective investigations. Many safety measures are already in place and the

training staff is knowledgeable and alert to safety concerns. Nonetheless, defensive tactics

should be further reviewed to determine whether additional safety measures can be implemented.

f. Improve reporting of information on injury mechanisms by obtaining information on

both the activity associated with the injury and the mechanism of injury.

g. Use the most common injuries identified in the retrospective and prospective

investigations to assist in medical planning. These injuries included strains, sprains, contusions,

and abrasions/lacerations.

h. Remain vigilant for symptoms of exertional rhabdomyolysis (ER). Although ER is an

infrequent diagnosis, the Physical Training Unit, as well as medical providers, should remain

knowledgeable about this problem and aware of the symptoms. New agents with persistent

symptoms or symptoms that exceed those of delayed onset muscle soreness should be escorted to

the medical clinic so their symptoms can be properly diagnosed.

i. Continue investigating associations between prior injury and pain that limits activity to

determine whether prophylactic measures can be put in place to reduce injury risk in training.


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CONTENTS

1. REFERENCES ........................................................................................................................ 1

2. INTRODUCTION AND PURPOSE ....................................................................................... 1

3. AUTHORITY .......................................................................................................................... 2

4. BACKGROUND ..................................................................................................................... 2

a. Injuries……………………………………………………………………………… ......... 2

b. Fitness…………………………………………………………………………… .............. 7

c. Associations between Fitness and Injuries……………………………………… ............ 10

d. Associations between Physical Activity and Injuries..……………………………… ...... 20

e. Associations between Tobacco Use and Injuries…………………………………… ...... 24

f. Exertional Rhabdomyolysis………………………………………………………… ....... 27

5. METHODS ............................................................................................................................ 30

a. FBI New Agent Training…………………………………………………………… ....... 30

b. Project Design……………………………………………………………………… ....... 31

c. Questionnaire………………………………………………………………………… ..... 31

d. Physical Characteristics and Demographics………………………………………… ...... 31

e. Physical Fitness Data………………………………………………………………… ..... 32

f. Final Student Status………………………………………………………………… ...... .34

g. Injury Data………………………………………………………………………… ........ .34

h. Data Analysis……………………………………………………………………… ...... ..35

6. RESULTS………………………………………………………………………… ........... ..37

a. New Agent Classes and Final Student Status………………………………………..…37

b. Descriptive Data on Injuries…………………………………………………………….38

c. Injury Incidence and Injury Rates……………………………………………………….42

d. Descriptive Statistics on Physical Characteristics, Demographics, and Questionnaire

Variables……………………………………………………………………………………43

e. Descriptive Statistics on Physical fitness Test Scores…………………………………...50

f. Univariate Associations of Injuries with Other Variables……………………………….53

g. Multivariate Analysis of Injury Risk Factors……………………………………………63


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7. DISCUSSION ....................................................................................................................... 65

a. Comparison of Injury Data in Retrospective and Prospective Investigations……… ....... 65

b. Comparison of FBI and Military Injury Incidence………………………………… ........ 72

c. FBI New Agent Fitness Compared to Other Groups…………………………………… . 73

d. Injury Risk Factors…………………………………………………………………… .... 76

e. Limitations……………………………………………………………………………… . 85

8. RECOMMENDATION ......................................................................................................... 86

Appendices

A. REFERENCES ................................................................................................................... A-1

B. INTERAGENCY AGREEMENT ....................................................................................... B-1

C. LIFESTYLE QUESTIONNAIRE……………………………………………………… ... C-1

D. NEW AGENT TRAINEE PROFILE FORM………………………………………… .... D-1

E. STANDARD FORM 88. REPORT OF MEDICAL EXAMINATION…………… ......... E-1

F. MEDICAL RECORDS DATABASE DESIGN AND CODING…………………… ....... F-1

G. CA-1 FORM. FEDERAL EMPLOYEE NOTICE OF TRAUMATIC INJURY AND CLAIM

FOR COTINUATION OF PAY COMPENSATION………………………………… .......... G-1

Use of trademarked names does not imply endorsement by the U.S. Army but is

intended only to assist in identification of a specific product.

USAPHC (PROV) REPORT NO. 12-HF-97HRF1A-10

PROSPECTIVE INVESTIGATION OF INJURY RATES AND INJURY RISK FACTORS

AMONG FEDERAL BUREAU OF INVESTIGATION NEW AGENT TRAINEES,


1. REFERENCES. Appendix A contains the scientific/technical references used in this report.

2. INTRODUCTION AND PURPOSE.

a. In April 2008, The Federal Bureau of Investigation (FBI) Human Resources Division,

Office of Medical Services, Health Care Programs Unit (HCPU), requested the assistance of the

United States Army Center for Health Promotion and Preventive Medicine (USACHPPM), now

the US Army Public Health Command, Provisional (USAPHC). The HCPU asked USAPHC

personnel to apply their experience in injury prevention programs in military training to assist in

injury prevention efforts in the FBI New Agent Training Program at the FBI Academy,

Quantico, Virginia (VA). On 24 April 2008, USAPHC representatives traveled to FBI

Headquarters for initial discussions. HCPU informed USAPHC of a number of recent cases of

rhabdomyolysis, but the discussions were broader, involving injuries of all types at the FBI

Academy. On 19 May 2008, a subsequent meeting was held at the FBI Academy at Quantico,

VA, hosted by the FBI's Assistant Director of the Training Division. On this date, USAPHC

briefed the training division, medical staff, and FBI Headquarters managers on similar program

evaluations and injury prevention recommendations USAPHC had made Army-wide. USAPHC

personnel proposed a methodology to evaluate injury incidence and injury risk factors among

FBI new agent trainees. FBI personnel provided USAPHC personnel with a tour of the FBI

Academy medical and training areas to further determine the feasibility of the project.

b. USAPHC and FBI representatives concluded that the project was feasible and two

projects were proposed. One project would be a retrospective examination of available records

to describe new agent injury rates and physical fitness, and to examine relationships between

physical fitness and injuries. The project would be carried out with medical data (available back

to 1999) in a medical database and physical fitness test data (available back to 2002) in another

computer database. A second, more detailed prospective project would involve fewer new agent

trainees and would progressively enroll new agent trainees as they entered the FBI Academy.

An Interagency Agreement (Appendix B) was completed on 5 February 2009. On 25 February

2009, USAPHC met with the medical staff and training division to make final arrangements for

data collection. The project began in March 2009.

c. This report details the results of the prospective portion of the project. The purpose of

this report is to examine the following in FBI new agent training: 1) injuries and injury rates

from March 2009 to March 2010, and 2) factors associated with these injuries. A previous report

covered the retrospective (historic) portion of the project.1 For simplicity, new agent trainees are

referred to as simply “new agents” throughout this report.


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3. AUTHORITY.

a. Under Army Regulation 40-5,2 the USACHPPM is responsible for providing

epidemiological consultation services upon request. This project was initiated by a request from

the FBI Human Resources Division, Office of Medical Services, and HCPU. The HCPU lacked

epidemiological support and under Title 31, United States Code, Section 1535, Economy Act, it

was considered appropriate to request the assistance of the PHC to study injuries and injury risk

factors in new agent training. An interagency agreement was developed and signed by the

appropriate parties (Appendix B).

b. Employing the criteria of the Council of the State and Territorial Epidemiologists,3

PHC determined that this project constituted public health practice. This decision was reviewed

by the Human Use Committee of the FBI who concurred with the determination.

4. BACKGROUND. This background section covers injuries and physical fitness, as well as

associations between injuries and fitness, physical activity, and cigarette smoking. Each section

begins with available literature on law enforcement, and then covers military and civilian groups

where literature is available on these groups. The final section covers information on the

definition, prevalence, risk factors, detection, and treatment of rhabdomyolysis, since this was a

special interest of the HCPU.

a. Injuries.

(1) Injuries in Law Enforcement Officers. This section focuses on injuries in law

enforcement offices. It should be noted that FBI new agents are not yet law enforcement officers

but rather officers in training and the FBI Academy training environment differs greatly from

actual law enforcement activities. Nonetheless, this review was conducted to show the paucity

of injury literature relating to law enforcement-related injuries.

(a) Only one study has examined injuries among new law enforcement officers in training,

although there were several other studies on veteran law enforcement officers. Sullivan and

Shimizu4 investigated workers’ compensation claims for injuries in the Los Angeles County

Sheriff’s Department. Injuries were defined as “claims [primarily] for strains, sprains,

contusions, abrasions, lacerations, fractures, gunshot wounds, bites and trauma”. During 4

months of training in 1982, 20% of students filed one or more injury-related workman’s

compensation claim; 4% of claims resulted in some form of injury-related disability. Compared

with male trainees, female trainees’ age-adjusted injury claims risk was 2.1 times higher; female

trainees’ risk of disabling injury claim was 4.3 times higher. There was no association between

age and injury rates in either men or women.


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(b) This same study4 also examined other law enforcement officers in the Los Angeles

County Sheriff’s Department. In 1982, the yearly incidence of workman’s compensation claims

filed by various subgroups was as follows: patrol deputies or detectives (n=2,428), 30%; deputies

on custody or court assignments (n=1,413), 15%; sergeants or higher ranking officers on patrol

or detective assignments (n=753), 15%; sergeants or higher ranking officers on custody or court

assignments (n=177), 12%. There were no gender differences across the entire group, and injury

claim incidence declined with age. The major external causes of the claims were altercations

(28%), foreign objects (20%), overexertion (19%), falls (17%), and vehicle crashes (6%). Major

injury sites were hand/wrist (23%), back (16%), and knee (10%). Most back injuries were

associated with overexertion (which included lifting/lowering, pushing/pulling) and most

hand/wrist injuries were associated with altercations.

(c) Three other studies examined injury-related events in veteran law enforcement

officers. Suyama et al.5 examined injury-related workman’s compensation claims from public

safety providers in an urban center (city not specified in the article) over a 29-month period. The

community had 850 policemen, 850 firefighters, and 144 emergency medical technicians

(EMTs). During the period, claims incidences were 169 claims/100 EMT, 71 claims/100 police,

and 56 claims/100 firemen. Time loss claims were 55 claims/100 EMT, 16 claims/100 police

and 16 claims/100 in firemen. EMTs had the highest rates of missed time, 20.1 days/100 EMTs

compared with7.7 days/100 firemen and 7.2 days/100 police.

(d) Brown et al.6 delivered a questionnaire on back pain and factors relating to back pain

to a randomly selected sample of Royal Canadian Mounted Police (n=1,002 of 14,897). They

found that 55% had reported chronic or recurrent back pain since serving as police officers and

only 9% had this problem before joining the force. The 1-year low back pain prevalence was

42%. There was no difference in the prevalence of back pain among those who did and did not

wear the duty belt (Sam Browne/Sam Black belts), nor among those who did or did not drive a

vehicle.

(e) Nabeel et al.7 administered a questionnaire to Minneapolis police officers that asked if

the officers had experienced back pain, strains, sprains, contusions, lacerations, gunshot wounds,

fractures, or chronic pain in the last 12 months. Incidence of reported sprains, back pain, and

chronic pain in the last year were 20%, 49% and 26%, respectively.

(2) Injury Rates and Injury Incidence in Military Basic Training.

(a) Basic military training shares some common characteristics with FBI new agent

training. Like basic military trainees, new agent trainees live with their fellow trainees in the

same barracks, eat in the same cafeteria, and perform all training with their fellow trainees.

There are also some differences between FBI new agent training and military basic training. FBI


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new agent trainees only train for a limited time during the day (generally 8 hours with additional

time for study); military personnel typically have much longer training days, often lasting 12-16

hours with only about 1 hour of personal time each day. The military conducts physical training

on an almost daily basis (unless a particular operational training activity is physically demanding

like obstacle courses, road marches, and the like). FBI new agents are expected to perform

physical training on their own (although they can attend a group training class), and there are 40

physically-demanding defensive tactics sessions included in the new agent training curriculum.

Military basic training lasts 6-12 weeks (depending on the service), while FBI new agent training

lasts about 21 weeks. It should also be noted that FBI new agents are older (average age about

30 years, compared to about 20 years in military trainees) and better educated (FBI new agents

have at least a bachelors degree, while the majority of military trainees are high school

graduates).

(b) Cumulative injury incidence (proportion of individuals experiencing one or more

injuries) and injury rates (injured trainees per month) have been examined in the basic military

training of the United States Army, Navy, Marine Corps, and Air Force.8-23

These data are

shown in Table 1. US Army Basic Combat Training (BCT) was extended from 8 to 9 weeks in

October 1998 and thus studies performed before and after this time are separated in Table 1 to

reflect the increased time at risk in the latter investigations. Two investigations are included for

US Army infantry basic training, which is 12 weeks long.

(c) Direct comparisons of service-specific rates in Table 1 are complicated by the use of

different injury collection methods and different injury definitions, even within the same service.

With regard to data collection, many investigations examined paper medical records,13, 14, 20, 24-27

but other studies used electronic medical surveillance systems9, 22, 23, 28-30

or questionnaires.15, 31

With regard to injury definitions, most studies have looked at cases where trainees reported to a

medical care provider for any type of physical damage to the body,9, 14, 16, 20, 22, 23, 26, 27, 30

but other

studies have included only musculoskeletal injuries13

or only lower extremity overuse injuries.13,

25, 32 One study used self-reporting and included any injury regardless of whether or not the

trainees sought medical care.15


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Table 1. Cumulative Injury Incidence and Injury Incidence Rates during Army, Navy, Marine

Corps and Air Force Basic Training

Service

Length of

Training

(weeks)

Study

(Reference

Number)

Year Data

Collected

Recruits (n)

Cumulative Injury

Incidence (%)

Injury Incidence Rate

(% / month)

Men Women Men Women Men Women

Army

8 weeks

Kowal

1978a,33 1978 347 770 26.2 62.0 13.1 31.0

Bensel

198314 1980 1,840 644 20.7 41.2 10.4 20.6

Jones et al.

199313 1984 124 186 27.4 50.5 13.7 25.3

Bell et al.

200024 1988 509 352 27.0 57.0 13.5 28.5

Westphal et

al. 199520 1994 ND 165 ND 66.7 ND 33.3

Jones et al.

199625 1996 159 84 41.5 65.5 20.8 32.8

Knapik et

al. 200116 1998 604 305 30.8 58.0 15.4 29.0

9 weeks

Canham et

al. 200026 1998 655 498 29.98 65.3 13.3 29.0

Knapik et

al. 2001b,27 2000 682/441 579/554 13.5/16.9 36.1/46.8 6.0/7.5 16.0/20.8

Knapik et

al. 2005bc,28 2003 442/569 295/377 19.5/27.9 41.0/47.7 8.7/12.4 18.2/21.2

Knapik et

al. 200822 2007 2,147 915 36.9 64.7 16.4 28.8

12 weeks

(Infantry)

Jones et al.

199312 1988 303 ND 45.9 ND 15.3 ND

d 1996 768 ND 48.0 ND 16.0 ND

US

Military

Academy

6 Weeks Bijur et l.

199734 1991 473 85 28.3 61.2 40.8 18.9

Marine

Corps 12 weeks

Linenger et

al. 199235 1990 8,076 ND 59.7 ND 19.9 ND

Alamedia

et al.

199931

1993 1,143 ND 39.6 ND 14.4 ND

Shaffer et

al. 199929 1995–96 ND 2,766 ND 44.0 ND 14.7

Almedia et

al. 199919 1993–94 176 241 25.6 44.0 9.3 14.7

Jones et al. 1993 434 366 22.8 53.0 8.3 17.7


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Service

Length of

Training

(weeks)

Study

(Reference

Number)

Year Data

Collected

Recruits (n)

Cumulative Injury

Incidence (%)

Injury Incidence Rate

(% / month)

Men Women Men Women Men Women

199936 1995 396 1,498 29 49 10.5 16.3

1995 2,546 ND 25 ND 9.1 ND

Rauh et al.

200632 1999 ND 824 ND 48.5 ND 16.2

Knapik et

al. 200930 2007 840 570 41.7 40.6 15.2 13.5

Navy 9 weeks Shaffer et

al. 199929 1996 ND 8,865 ND 37.2 ND 12.4

Air Force 6 weeks

Snedecor et

al. 20009 1994–95 8,660 5,250 16.8 37.8 11.2 25.2

Knapik et

al. 200823 2007 1,979 723 27.6 46.9 18.4 31.3

Legend: Notes:

ND = no data collected on this gender a Injury data from self-report questionnaire

b Cohort study with two groups

c Injury data from surveillance system

d Previously unpublished data (1998)

(d) Table 2 shows studies that have examined injuries in the basic training of various

foreign armies. Most studies involved only men but Heir and Glomsaker37

and Kerr et al.38

included women. The study of the Chinese Armed Forces by Wang et al.39

apparently followed

new recruits for one year and likely involved more than just basic training. Wang et al. stated

that most injuries occurred in the first 12 weeks, but the cumulative incidence is still lower than

for any other type of training regardless of training length. With the exception of Wang et al.39

,

monthly overall injury rates varied from 7% to 15%. Differences in injury definitions and

differences in specific training environments likely account for at least a portion of these

differences.


7

Table 2. Studies of Foreign Army Basic Training Study Situation Length of

Training

(weeks)

N Injury Definition Cumulative

Incidence (%)

Injury Rate

(injured

trainees/month)

Gordon et

al. 198640

South African

Basic Training

10 947♂ Acute or overuse event

resulting in ≥1 day limited

duty

Any: 37.9

Acute: 7.4

Overuse: 32.4

Any: 15.2

Acute: 3.0

Overuse: 13.0

Jordan &

Schwellnus

199441

South African

Basic Training

10 1,151 ♂ Occurrence due to activity

with medical consult and

≥1 day limited duty

31.9a 14.1a

Heir et al.

199637, 42

Norwegian

Conscript

Basic Training

Army: 8-10

Air Force: 8-10

Navy: 6-8

Army: 2,379b

Air Force: 1,519b

Navy: 2,593b

Pain, inflammation, or

functional disorder

involving musculoskeletal

or soft tissue with visit to

medical personnel

Army: 27.3

Air Force: 21.6

Navy: 13.0

Army: 12.1c

Air Force: 9.6c

Navy: 7.4c

Heir and

Eide 199743

Norwegian

Army

Conscript

Basic Training

10 480 ♂ Pain, inflammation, or

functional disorder

involving musculoskeletal

or soft tissue with visit to

medical personnel

24.4 9.8

Rosendal et

al. 200344

Danish

Conscript

Basic Training

12 349 ♂ Lower extremity events

involving pain,

inflammation, or functional

disorder of musculoskeletal

or soft tissue with ≥1 day

limited duty

26.4 6.6

Wang et al.

200339

Chinese Armed

Forces Police

52 807 ♂ Physical damage to bone,

soft tissue or organs with

≥1 day limited duty

13.8 1.2

Kerr 200438 Irish Basic

Training

16 354 ♂

40 ♀

Not clear ♂ 53.1

♀ 67.5

13.3♂

16.9 ♀

Notes: aNot clear if cumulative incidence or if incidence of all new injuries (i.e., a person could have been injured more than once) bAuthors stated that 1% were women cNine weeks used in calculation for Army and Air Force; 7 weeks used in calculation for Navy

b. Fitness.

(1) Fitness in Law Enforcement Officers.

(a) Two studies were found on the physical fitness of new law enforcement officers in

training. Stamford et al.45

examined initial and final fitness levels in 54 men and 7 women in a

12-week recruit training program for the Louisville Police Department. Scheduled exercise

duration and frequency was at least 1 hour per day, 5 days per week. Physical training

emphasized running but also included calisthenics, weight training, and combatives. Before and

after training, VO2max, a measure of aerobic fitness, was measured with a discontinuous cycle

ergometer protocol and body fat was determined by densitometry. Initial fitness levels (pre-

training) and changes in fitness (post-training) are shown in Table 3. Men increased VO2max,


8

and pull-up performance and decreased body fat. Women had more than double the relative

improvement of the men and also increased their flexed arm hang performance but had more

modest changes in body fat. The greater aerobic improvement of the women was probably due

to their lower initial VO2max, since a number of studies have demonstrated that lower initial

aerobic fitness leads to greater relative gains46

. Fifteen male recruits were retested after one year

on duty. The results of the follow-up (obtained from graphs in the article) are shown in Table 4.

Results generally show that the officers returned to their pre-training weight, body fat and

aerobic fitness, although some upper body strength was retained.

Table 3. Initial Fitness and Changes in Fitness after Louisville Police Officer Recruit Training

(values are mean±SD, empty cells data were not provided by the authors) Variables Men (n=54) Women (n=7)

Pre-Training Post-Training Change (%) Pre-Training Post-Training Change (%)

Age (yrs) 25.2±3.7 ----- ----- 24.1±5.1 ----- -----

Height (in) 70.6±1.6 ----- ----- 67.5±2.4 ----- -----

Weight (lbs) 180.2±26.0 178.1±23.4 -1.1 137.8±8.4 134.8±8.1 -2.2

Body Fat (%) 17.7±4.5 15.8±3.8 -10.9a 25.1±4.1 23.9±3.2 -4.6

VO2max (ml/kg/min) 36.5±5.8 44.3±5.8 21.3a 29.3±4.2 42.7±30 45.7a

Pull-Ups (n) 5.2±3.3 6.4±3.8 24.5a ----- ----- -----

Flexed Arm Hang (sec) ---- ---- ----- 27.3±3.6 30.7±1.9 12.6a

Note: aStatistically significant change, p<0.05

Table 4. Mean Values for Initial Fitness, Changes in Fitness after Police Officer Recruit

Training, and Fitness One Year of Active Duty (n=15 men)a Variable Pre-Training Post-Training One Year

Active Duty

Weight (lbs) 172 165 174

Body Fat (%) 17.9 16.1 17.2

VO2max (ml/kg/min) 35.1 50.2 35.5

Pull-Ups (n) 4.5 7.0 6.0

Note: aValues are approximate since they were obtained from a graph

(b) Another study of North Carolina law enforcement trainees examined the effectiveness

of a health and fitness training program. There were nine groups at two sites over two years.

The entire law enforcement training curriculum was 397 hours, 43 hours of which were devoted

to the health and fitness training. The health and fitness training course was 12 weeks and

included 4 hours of classroom wellness instruction and 3 hours of testing. Exercise sessions

were 3 hours each week and involved 20 minutes of aerobic activity (running in groups, cycle

ergometers) with muscular endurance/strength training (push-up, sit-up, weight training). As

shown in Table 5, body fat was reduced and sit-up performance increased.47


9

Table 5. Initial Fitness and Changes in Fitness after North Carolina Police Officer Recruit

Training (values are mean±SD where available, empty cells indicate that data were not provided

by the authors) Variables Men (n=74-136) Women (n=17-33)

Pre-

Training

Post-Training Change (%) Pre-Training Post-Training Change (%)

Age (yrs) 26.4 ----- ----- 26.8 ----- -----

Height (in) 70.4 ----- ----- 65.2 ----- -----

Weight (lbs) 189.4±36.5 188.6±34.0 -0.4 150.3±33.4 148.6±30.4 -1.1

Body Mass Index (kg/m2) 26.5±4.7 26.3±4.2 -0.7 24.5±3.4 24.5±2.9 0.0

Body Fat (%) 17.0±6.9 14.8±6.0 -12.9 27.0±6.9 25.0±7.1 -7.4

Sit-ups (n) 38±9 49±10 28.9 31±7 44±7 41.9

Note: aStatistically significant change, p<0.05

(c) Besides law enforcement trainees, a number of studies have examined physical fitness

among law enforcement officers in active service. Table 6 provides a summary of these

investigations and details of the testing methods are listed in the table footnotes. One study on

the Greensboro Police Department48

was excluded from Table 6 because both men (n=9) and

women (n=3) were combined in the descriptive statistics and there are major gender differences

in performance of fitness events. Pollock et al.49

performed fitness testing on a large number of

police officers in the Dallas and Richardson, Texas, Police Departments. They separated the

initial cohort into younger (21-35 years) and older (36-52 years) groups for analysis but only the

younger group is shown since they are closer in age to FBI new agent trainees. Rhodes and

Farenholtz50

noted that their subjects were “randomly selected” but they do not specify how the

selection was accomplished or where the law enforcement officers were located. Smolander et

al.51

examined the physical fitness of 95 Finnish police officers who were in an officer training

course but had been performing police work for at least 7 years. Standish et al.52

had a mixed

group of Royal Canadian Mounted Police recruits and college students, but did not separate the

two groups in the descriptive statistics.


10

Table 6. Selected Fitness Measures on Various Law Enforcement Officers Groups Measure Cleveland

State

University

Police,

n=15

men53

Dallas &

Richardson

Police

n=153

men49

Canadian Police50 Finnish

Police,

n=90-95

men51

Canadian Police

Recruits (n=28) &

College Students

(n=20)52

Men

(n=78)

Women

(n=27)

Men

(n=21)

Women

(n=27)

Age (years) 29±5 21-35 31±4 28±3 34 24±3 23±2 Weight (kg) 87±15 83±12 86±10 66±9 84±10 75±11 63±9 Height (cm) 179±9 179±6 181±6 168±6 181±5 180±10 170±10 Body Mass Index (kg/m2)a 31.2a 25.9a 26.3a 23.4a 25.6a 23.9±2.7 22.8±3.4 VO2max (ml/kg/min) 38.0±6.4b 40.7±4.5b 44.1±6.7b 39.0±6.7b 41.2±10.0h

ND ND 1.5 mile Run (min) ND ND ND ND ND 11.4±2.1 13.3±3.0

Push-ups (repetitions) ND 21±8g 29±12c 11±11d ND 39±14c 21±11c Pull-Ups (repetitions) 3.9±2.4 ND 7.8±4.1 1.3±2.1 4.8±3.4 ND ND Sit-Ups (repetitions) 33±8e 34±6ef 33±8ef 38±9ef 21±3eg 47±10ef 43±13ef Legend: ND=Not data reported

Notes:

aCalculated from height and weight bGraded running treadmill test with oxygen uptake cContinuous until participant could not maintain continuous motion dContinuous until participant could not maintain continuous motion, knees on ground eBent knee sit-ups fMaximum in 1 minute gMaximum in 30 sec hEstimated from submaximal bicycle ergometer test

c. Associations between Fitness and Injuries.

(1) Law Enforcement Studies.

(a) Two studies examined associations between fitness and injury in law enforcement

groups. Nabeel et al.7 administered a questionnaire to Minneapolis police officers to explore

relationships between fitness, physical activity, and injury. The questionnaire asked if the

officers had experienced back pain, strains, sprains, contusions, lacerations, gunshot wounds,

fractures, or chronic pain in the last 12 months. Questionnaire items also asked about age,

height, weight, self-rated fitness, and physical activity. Only selected data on specific

association were reported in the article and those data are shown in Tables 7 and 8. Table 7

shows relationships between specific types of pain/injuries and exercise intensity, fitness level,

and physical activity. Those with higher self-reported exercise intensity, higher self reported

fitness or higher overall physical activity were less likely to report sprains, back pain or chronic

pain in the last year. The authors performed a multivariate logistic regression analysis to

examine the association between various types of injuries and the other variables. A summary of

these data are in Table 8. The selectively reported data showed that: 1) officers with a body

mass index (BMI) >35 kg/m2 were over 3 times more likely to report back pain compared to

those with BMI<35 kg/m2; 2) those exercising less that 30 minutes, 4 times/week were 73%


11

more likely to report back pain compared with those exercising more than 30 minutes, 4

times/week; 3) those with the lowest level of self-reported fitness were about twice as likely to

report back pain and about 75% more likely to report sprains and chronic pain, compared with

those with the highest level of self-reported fitness; 4) those in the lowest quartile of physical

activity were more likely to report back pain and chronic pain compared with those in the highest

quartile of physical activity. The data indicated that higher levels of self-reported fitness, higher

levels of physical activity, and lower BMI were associated with lower incidence of specific self-

reported injuries.

Table 7. Associations between Injuries and Various Fitness and Physical Activity Variables in

Minneapolis Police Officers (Univariate Analysis) Variable Level of Variable Odds Ratios (95% Confidence Intervals)

Back Pain Sprains Chronic Pain

Exercise

Intensity

Low

High

1.00

0.70 (0.50-0.97)

1.00

0.82 (0.44-1.50)

1.00

0.51 (0.21-1.21)

Self-Reported

Fitness

Lowest Level (scale of 4)

Highest Level (scale of 4)

1.00

0.45 (0.27-0.76)

1.00

0.40 (0.20-0.83)

1.00

0.33 (0.15-0.71)

Calculated

Activity Scale

Lowest Quartile

Highest Quartile

1.00

0.60 (0.43-0.82)

1.00

0.84 (0.49-1.44)

1.00

0.55 (0.32-0.95)

Table 8. Associations between Injuries and Various Fitness and Physical Activity Variables in

Minneapolis Police Officers (Multivariate Analysis) Variable Level of Variable Odds Ratios (95% Confidence Intervals)

Back Pain Sprains Chronic Pain

Body Mass

Index

<35 kg/m2

>35 kg/m2

1.00

3.36 (1.17-9.66)

ND ND

Exercise <30 minutes, 4 times/week

>30 minutes, 4 times/week

1.00

0.27 (0.12-0.65)

ND ND

Self-Reported

Fitness

Lowest Level (scale of 5)

Highest Level (scale of 5)

1.00

0.48 (0.09-0.88)

1.00

0.27 (0.08-0.88)

1.00

0.21 (0.06-0.73)

Physical

Activity

Lowest Quartile

Highest Quartile

1.00

0.37 (0.10-0.73)

ND 1.00

0.42 (0.19-0.91)

Legend: ND=No data reported

(b) The second study examining associations between fitness and injury in law

enforcement officers included 363 officers in the city of Austin, Texas.54

The participants were

given a fitness assessment that included a maximum treadmill exercise test (Bruce protocol).

The outcome measure was medical care claims of any type and included many claims not related

to injury. Medical care claims were lower for the more aerobically fit officers, but the

differences were not statistically significant (p=0.17). Unfortunately, the risk of a claim was not

reported for the different fitness levels. Absenteeism was also examined in this study, but

absences due to injuries were specifically excluded from the analysis.


12

(2) Military Studies.

(a) Associations between injuries and physical fitness have been extensively examined in

the military services and studies have involved both basic combat training and operational

military units. The basic training studies are shown in Table 9. Regardless of service (Army,

Air Force, Marine Corps), higher injury risk was associated with lower aerobic fitness when the

latter was measured by VO2max, 1-mile run, 1.5-mile run, 2-mile run, or 3,000-meter run.10, 11,

13, 16, 20, 23, 31, 32, 34, 36, 42, 43, 55, 56 Higher injury risk has been associated with less upper body

muscular endurance, whether the latter is measured with push-ups, pull-ups, or the flexed arm

hang.12, 13, 16, 20, 30, 57-59

Higher injury risk has been associated with lower abdominal muscular

endurance when the latter is measured with sit-ups or crunches.16, 20, 30, 58, 59

Table 9. Associations between Levels of Fitness And Injuries in Various Groups of Military

Recruits Study Group Injury Case Definition Fitness

Measure

Fitness Levels Being Compared Risk Ratio (95%

Confidence

Interval)a

Jones, et al

199312

135 ♂ US Army

infantry basic

trainees

Lower extremity

musculoskeletal injury

2-mile run 17.1-22.3 / 11.9-13.8 min 1.6 (0.7-3.4)

Push-ups 1-16 / 35-57 repetitions 2.0 (1.2-6.0)

Jones et al.

199313

79 ♂ US Amy

basic trainees

Physical damage

resulting in ≥1 day of

limited duty

1-mile run

7.7-11.5 / 5.9-6.4 min b


140 ♀ US Army

basic trainees

1-mile run

10.4-16.3 / 6.0-9.0 min 1.9 (0.8-4.2)


Westphal

et al.

199520

159-163 ♀ US

Army basic

trainees

A traumatic or overuse

event resulting in a

visit to a medical care

provider and ≥1 day

limited duty

Push-ups <2 / >16 repetitions 1.38 (0.86-2.22)

Sit-ups <21 / >48 repetitions 1.29 (0.75-2.21)

2-mile run >26.5 / <21.0 minutes 1.55 (1.03-2.32)

Canham et

al. 199657

156 ♀ US Army

basic trainees

Not defined 2-mile run Slowest quartile/fastest quartile 1.8 (1.1-2.9)

95 ♂ US Army

basic trainees

Push-ups Lowest performing

quartile/highest performing

quartile

1.5 (1.0-2.1)

Bijur et al.

199734

437 ♂ US

Military

Academy Cadets

Overuse or traumatic

energy exchange

resulting in physical

damage and ≥1 day of

limited duty

2-mile run mean 19.6 / mean 12.0 min 3.0

85 ♀ US

Military

Academy cadets

2-mile run mean 15.6 min/mean 12.0 min 1.9


13

Study Group Injury Case Definition Fitness

Measure


Confidence

Interval)a

Heir et al.

199642

912 Norwegian

Air Force

conscripts


functional disorder

involving

musculoskeletal or soft

tissue with visit to

medical personnel

3000-meter

run

14.7-24.0 / 9.4-12.0 min 1.9 (1.2-3.1)

Heir et al.

199743

449 ♂

Norwegian

infantry

conscripts


functional disorder

involving

musculoskeletal or soft

tissue with visit to

medical personnel

3000-meter

run

14.8-23.2 / 10.4-13.3 min 1.5 (1.0-2.3)

Shaffer et

al. 199956

1,078 ♂ US

Marine Corps

recruits

Stress fractures 1.5 mile run 12.3-17.2 / 8.2-10.5 min 3.1 (1.3-7.7)

Knapik et

al. 200116

670 ♂ US Army

recruits

Physical damage

resulting from overuse

or trauma


Sit-ups 0-31 / 49-85 repetitions 1.6 (1.0-2.4)

2-mile run 19.2-31.6 / 10.4-15.4 min 1.6 (1.0-2.4)

VO2max 40-47 / 53-70 ml/kg/min 1.9 (1.0-3.7)

385 ♀ US Army

recruits



2-mile run 23.5-28.7 / 13.0-19.5 min 1.9 (1.2-2.8)

VO2max 30-37 / 41-57 ml/kg/min 1.9 (1.1-3.4)

Trank et al.

200160

1,703 ♂ US

Naval recruits

Not stated 1.5-mile run 25.5-43.5 / 11.5-17.5 min 1.4 (1.0-1.8)

Rauh et al.

200632

812 ♀ Marine

Corps recruits

Lower extremity non-

stress fracture overuse

injury

1.5-mile run Slowest quartile/fastest quartile 1.3 (0.9-2.0)

Stress fracture 1.5-mile run Slowest quartile/fastest quartile 2.6 (1.2-5.8)

Shaffer et

al. 200661

2,767 ♀ Marine

Corps recruits

Stress fracture 0.75 or 1-

mile run

Slowest quartile/fastest quartile 3.1 (1.3-7.8)

Knapik et

al. 200958

1,240-1,330 ♂

US Army

recruits

Specific International

Classification of

Disease, Version 9

codes indicative of

physical damage



2-mile run 20.3-32.2 / 11.7-16.0 min 1.5 (1.2-2.0)

467-516 ♀US

Army recruits



2-mile run 24.8-31.3 / 12.3-19.4 min 2.2 (1.6-3.0)

Knapik et

al. 201059

1,713-1,729 ♂

US Air Force

recruits


Classification of

Disease, Version 9

codes indicative of

physical damage


Crunch 0-30 / 45-75 repetitions 1.5 (1.2-2.0)

1.5-mile run 14.0-20.5 / 8.3-11.5 min 1.5 (1.1-1.9)

680-684 ♀US

Air Force

recruits



1.5-mile run 18.2-31.4 / 9.7-14.9 min 1.6 (1.2-2.2)


14

Study Group Injury Case Definition Fitness

Measure


Confidence

Interval)a

Knapik et

al. 201062

782 ♂ US

Marine Corps

recruits


Classification of

Disease, Version 9

codes indicative of

physical damage

Pull-ups 0-4 /12-26 repetitions 1.6 (1.2-2.2)


1.5-mile run 12.0-15.0 / 8.3-10.5 min 2.0 (1.5-2.8)

566-567 ♀US

Marine Corps

recruits

Flexed arm

hang

5-30 / 59-70sec 1.4 (1.0-1.9)

Crunch 13-51/ 81-130 repetitions 1.8 (1.2-2.6)

1.5-mile run 14.8-17.4 / 10.1-13.0 min 1.9 (1.3-2.8)

Notes: aSome authors provided odds ratios or 90% confidence intervals so data were recalculated.

bLowest risk group had no injuries and highest risk group had 36.8%with one or more injuries. Risk ratio cannot be

calculated when there are no injuries in a group.

(b) The military studies above examined associations between fitness and injury did not

provide injury risk at identical levels of fitness that would allow for the most appropriate

comparisons among studies. For example, time to complete a 2-mile run could be partitioned

into 9.0-9.9 minutes, 10-10.9 minutes, 11.0-11.9 minutes, etc. and then the injury risk at each

time period could be determined. Rather than use a common cutpoint method like this one, most

studies partitioned fitness levels into tertiles, quartiles, or quintiles. Using tertiles, quartiles, or

quintiles optimizes sample sizes at each fitness level because a maximum number of individuals

are included in each grouping, each subject is included, and there are no groups with small

sample sizes that might have low statistical power. Despite these advantages for individual

studies, this method complicates direct comparisons among studies because different

investigations have different tertile/quartile/quintile cutpoints depending on the distribution of

scores. Nonetheless, injury comparisons among studies can still be made by paying careful

attention to the cutpoints. The largest differences are likely found among the least fit and the

most fit (indicated by the two extreme quartiles or quintiles).

(c) Some further issues in direct comparisons across military studies are introduced by

examining different fitness tests that presumably measure the same fitness component. For

example, both a 1-mile and a 2-mile run are considered measures of cardiorespiratory endurance;

however, the 1-mile run will recruit more anaerobic energy sources, will likely make greater use

of Type II muscle fibers, and will require more muscular force per stride than a 2-mile run.63

Nonetheless, both are measures of cardiorespiratory endurance since both have a moderate to

high correlation with VO2max, the criterion measure of aerobic fitness.64, 65

Besides tests of

aerobic fitness, different muscular endurance tests will recruit different muscle groups and some

muscle group specificity might be expected because of individual differences in total muscle

mass at different sites. Despite this, factor analysis has indicated that push-ups, pull-ups, and the

flexed arm hang produce high factor loadings on tests that appear to involve upper body

muscular endurance. Sit-ups and holding a half-sit (similar to crunches) produce high factor

loading on tests that appear to involve abdominal muscular endurance.66-68


15

(d) With the above limitations in mind, meta-analysis was performed on military studies

in Table 9 using a general variance based method.69

This method uses risk ratios and 95%

confidence intervals to produce a summary risk ratio and summary 95% confidence interval

representing the pooled results of all the studies. Studies examining upper body muscular

endurance and using the push-up, pull-up, or flexed arm hang were combined.12, 13, 16, 30, 57-59

Studies examining abdominal muscular endurance and using the sit-up or crunch were

combined.16, 30, 58, 59

Studies examining aerobic (cardiorespiratory) endurance and using runs of 1

to 2 miles were combined.12, 13, 16, 30, 43, 56-60

Studies by Shaffer et al.61

and part of the study by

Rauh et al.32

were not included since they examined only stress fractures and not the overall

incidence of injuries. The study by Bijur et al.34

could not be included because no confidence

intervals were provided in the article. Table 10 shows the results of the meta-analysis. Values in

Table 10 for upper body muscular endurance and abdominal muscular endurance are likely

overestimated. This is because some studies that likely collected these data12, 13, 32, 57, 60

did not

report the results, possibly because of lack of an association between the measure and injury.

More certainty can be placed on the association between injuries and aerobic endurance since all

available studies reported these values or the data could be calculated from the information

provided.

(e) Table 11shows studies in other military groups other than basic trainees that have also

examined associations between fitness and injury. Results for these groups are not as clear as for

basic trainees.

Table 10. Summary Risk Ratios and Summary 95% Confidence Intervals for Military Recruit

Studies Examining Associations between Fitness and Injuries Fitness Measure Summary Risk Ratios –

Least Fit Group/Most Fit Group

(Summary 95% confidence intervals)

Men Women

Upper Body Muscular Endurance (Push-Up, Pull-Up, Flexed Arm Hang) 1.6 (1.4-1.8) 1.5 (1.3-1.8)

Abdominal Muscular Endurance (Sit-Up, Crunch) 1.4 (1.2-1.6) 1.4 (1.2-1.7)

Aerobic Endurance (Runs - 1.0, 1.5, 2.0 miles; 3000-meter) 1.6 (1.5-1.8) 1.7 (1.5-2.0)


16

Table 11. Studies of Various Military Groups Examining Associations between Fitness and

Injuries Study Injury Case Definition Group Fitness

Measure

Level of Fitness Measure Risk Ratio

(95%

Confidence

Interval)a

Knapik et

al. 199070

Any acute or overuse

event in the Soldier’s

medical record in last 6

months

298 ♂ Infantry

Soldiers

Push-Ups Lowest /highest performing quartile 1.2 (0.8-1.7)

Sit-Ups Lowest /highest performing quartile 1.9 (1.2-2.8)

2-Mile Run Lowest /highest performing quartile 1.6 (1.1-2.4)

Reynolds

et al.

199471

Any acute or overuse

event in the Soldier’s

medical record in last year

154 ♂ Infantry

Soldiers

Push-Ups Lowest /highest performing quartile 1.2 (0.7-2.2)

Sit-Ups Lowest /highest performing quartile 1.5 (0.9-2.4)

2-Mile Run Lowest /highest performing quartile 1.6 (0.8-3.0)

Knapik et

al. 199972

An event resulting in

physical damage to the

body & documented visit

to a medical care provider

in last 10 months

156-162 ♂

senior US

Army officers

at the US

Army War

College

Push-Ups 25-42 / 71-121 repetitions 1.0 (0.8-1.5)

Sit-Ups 28-47 / 73-103 repetitions 1.2 (0.8-1.8)

2-Mile Run 16.5-19.6 / 11.6-14.1 min 1.1 (0.8-1.5)

Knapik et

al. 200673

An event that resulted in

physical damage to the

body and documented

visit to a medical care

provider in last year

104 ♂US

Army wheel

vehicle

mechanics



2-Mile Run 15.3-19.0 / 12.1-14.1 min 0.9 (0.5-1.8)

Knapik et

al. 200674


Classification of Disease,

Version 9 codes indicative

of physical damage in last

year

152-192 ♂ US

Army Band

Members



2-Mile Run 17.2-18.8 / 12.0-15.2 min 1.5 (1.0-2.2)

32-44 ♀ US

Army Band

Members



2-Mile Run 19.3-22.8 / 14.7-17.8 min 1.3 (0.2-1.6)

Knapik et

al. 200775

Physical damage to the

body with a visit to a

medical care provider and

≥1 day limited duty in the

last year

643-656 ♂

Infantry

Soldiers



2-Mile Run 11.7-13.5 / 15.3-24.5 min 1.9 (1.1-3.2)

Wilkerson

et al.

200976

Physical damage to the

body with a visit to a

medical care provider and

≥1 day limited duty in the

last year

576-578♂

British Infantry

Soldiers



1.5-Mile Run 10.2-13.7 / 7.4-9.3 min 1.0 (0.7-1.4)

(3) Civilian Studies.

(a) Civilian studies that have examined associations between fitness and injuries have

produced mixed results. Interpretation of these studies is complicated by different injury

definitions, different subject populations, and variable follow-up times. Univariate analyses of

fitness and injury associations that could be used in meta-analyses are seldom provided.


17

(b) Two studies reported an association between higher fitness and lower injury risk.77, 78

Cady et al.77

gave a number of tests to 1,652 Los Angeles County firefighters and subsequently

followed them up for workman’s compensation claims for back injuries. A “fitness index” was

developed that included 1) work (watts) at the end of a 20-minute heart rate controlled test (test

protocol not specified), 2) total isometric strength of selected muscle groups, 3) spine rotation

flexibility, 4) diastolic blood pressure during exercise at a heart rate of 160 beats per minute, and

5) heart rate 2 minutes after a standardized bicycle exercise. The isometric strength test involved

an upright pull but it is not clear if other tests were included. The exercise test apparently

involved the workload achieved at a heart rate of 160 beats per minute. Workman’s

compensation claims for back injuries were subsequently followed but the follow-up period is

not stated. The 16% of individuals with the lowest fitness index were 9.9 times (95%CI=2.3-

42.0) more likely to file a claim for a back injury than the 16% of individuals with the highest

fitness index.

(c) Studnek et al.78

performed a case-control study of a stratified random sample of 574

nationally registered emergency medical technicians. A questionnaire that was administered

asked the technicians to self-rate their physical fitness on a 4-point Likert scale. A year later

they were asked if they had experienced any back problems in the last year. Those who self

reported fair to poor physical fitness were 2.3 times (95%CI=1.2-4.4) more likely to report a

back problem in the follow-up period compared with those reporting excellent physical fitness.

(e) In contrast to the civilian studies reporting that higher injury risk was associated with

lower fitness,77, 78

some civilian studies have found no association between fitness and pain or

injuries.79-81

Battie et al.80

examined 2,434 industrial workers at the Boeing Seattle plant. A

submaximal, graded, walking treadmill test providing an estimated VO2max was administered to

the workers. Over the next 4 years, back problems requiring treatment or surgery were obtained

from incident reports or medical claims. Little association between estimated treadmill VO2max

and subsequent back problems was found after controlling for age and gender.

(f) Varstappen et al.81

administered a battery of fitness tests to 136 physical education

students and subsequently followed them for injuries over a 4-year period. Tests included the

bent arm hang (arm/trunk static strength), arm pull (static arm strength), vertical jump (leg

power), leg lifts (leg/trunk muscular endurance), sit-and-reach (flexibility), 10 X 5-meter sprints

(anaerobic capacity), plate tapping (arm speed), and a multi-stage 20-meter shuttle run

(cardiorespiratory endurance). Once every 3 weeks over the 4-year period, students recorded

any injuries they experienced. Injuries were defined as “physical discomfort sustained during

physical activity that hindered the subject practicing sports lessons”. Low injury proneness was

defined as experiencing <3 injuries in 4 years and high injury proneness was defined as ≥4

injuries in 4 years. Injury proneness showed little relationship with any items on the test battery.

Students were very fit to begin with, scoring in the 7th

to 10th

reference deciles (higher fitness)


18

for the tests compared with a sedentary reference population. Most physical education students

were in the 9th

and 10th

deciles. This limited the range of scores making it difficult to

discriminate among fitness levels and this may account for the lack of relationship between

injury proneness and fitness.

(g) Several other studies of free-living individuals have shown that those who are more

aerobically fit are more likely to become injured.82-87

All but one of these studies82

involved

individuals who were given an initial fitness test at a preventive medicine clinic (Cooper Clinic,

Dallas, Texas) and followed up for self-reported injuries over various time periods. A summary

of the Cooper Clinic studies is shown in Table 12. All studies in Table 12 used time to

exhaustion on a graded treadmill test (Balke protocol) as the measure of aerobic fitness. Low fit

individuals were those in the ≤20th

percentile of treadmill times; moderate fit individuals were

those in the 21st to 60

th percentile of treadmill times; and high fit individuals were those in ≥ 61

st

percentile of treadmill times. In order to determine risk ratios it was necessary to perform a

secondary data analysis on some of the studies. One Cooper Clinic study87

did not provide

adequate information for this purpose and thus is not included in the table. No meta-analysis

was performed because the subject populations likely overlapped in many of the studies. It is

apparent by examining the last column of Table 12 that those in the high fitness category are at

higher injury risk than those in the low fitness category.


19

Table 12. Studies Examining Associations between Aerobic Fitness and Injuries in Free-Living

Individuals Study Injury Case Definition Subjects Fitness Level Risk Ratio (95%

confidence interval)

Hootman et

al. 200185

Self-reported activity-related

injury in the last year

4,034 ♂ attending preventive

medicine clinic (Cooper Clinic)

Low

Moderate

High

1.00

2.38 (1.57-3.61)

4.50 (3.02-6.70)

967 ♀ attending preventive


Low

Moderate

High

1.00

1.42 (0.75-2.67)

2.18 (1.19-3.97)

Hootman et

al. 200284


injury in the last year resulting

in taking medication,

consulting physician, or

stopping/reducing activity

5,028 ♀ attending preventive


Low

Moderate

High

1.00

1.27 (0.70-2.36)

1.85 (1.50-2.29)

1,283 ♀ attending preventive


Low

Moderate

High

1.00

1.05 (0.73-1.52)

1.41 (1.00-1.99)

Hootman et

al. 200283

Self-reported lower extremity

injury in the last 5 years after

starting a running, walking or

jogging program; injury

resulted in consulting a

physician



Low

Moderate

High

1.00

1.55 (1.16-2.07)

1.94 (1.47-2.56)



Low

Moderate

High

1.00

1.12 (0.70-1.79)

1.24 (0.79-1.93)

Colbert et

al. 200086


injury in the last year

requiring a physician visit



Low

Moderate

High

1.00

1.02 (0.62-1.68)

1.62 (1.01-2.59)



Low

Moderate

High

1.00

3.03 (0.77-11.87)

2.73 (0.71-10.45)

(h) One study by Blair et al.82

did not examine Cooper Clinic clients but rather

individuals participating in worksite health promotion programs. A baseline examination

included a treadmill test and a sit-up test (repetitions completed in1minute). Those starting an

exercise program were asked if they experienced any bone, muscle, or joint injury in the

previous year (this may have included more than just activity-related injuries). Discriminate

function analysis demonstrated that higher injury risk was associated with higher aerobic fitness

(treadmill time) or more sit-ups. Univariate analysis of injury and the fitness measures were not

provided.

(4) Comparison of Military and Civilian Studies. There were considerable

methodological differences between the military basic training and civilian studies. First,

injuries in military basic training studies were obtained from documented events in the medical

records; most injuries in the civilian studies (with the exception of Ready et al.79

and Battie et

al.80

) were obtained from self-reports, which are subject to recall bias. Second, the military basic

training environment is much more controlled than that of the civilian studies because of the

standardized living, sleeping, eating, and activity conditions mentioned above. These factors are

uncontrolled and variable in civilian studies and less controlled in the military outside the basic

training environment. The similar physical activity is likely the major factor that allows the


20

association between fitness and injury to be consistently demonstrated in military basic training

studies. Nonetheless, in one study, Hootman et al.85

controlled for type and duration of physical

activity (from self reports) and higher aerobic fitness was still associated with higher injury risk.

Third, the majority of individuals in military basic training studies are young (average age about

20 years, range 17 to 35 years), while in the Cooper Clinic studies individuals were older

(average age about 40 years, range 20-85 years). As pointed out by Hootman et al.85

, older

individuals may have more lifetime injuries that could affect their reporting of current injuries

due to either the chronic or recurrent nature of some injuries.

d. Associations between Physical Activity and Injuries.

(1) Aside from the study by Nabeel et al.7 discussed earlier, no other investigation

examined associations between physical activity and injury in law enforcement officers.

Nonetheless, several studies were found on self-assessed physical activity among law

enforcement officers54, 88-91

that provided some descriptive information on the amount of

physical activity performed. Steinhardt et al.54

evaluated physical activity among City of Austin,

Texas, law enforcement officers from responses on a health risk appraisals (HRA). Responses

on the HRA were placed into three categories: 1) little or no physical activity, 2) occasional

physical activity, or 3) regular physical activity at least 3 times/week. Table 13 shows the

proportion of the officers who fell into each of these categories. Franke and Anderson91

asked

Iowa Department of Public Safety law enforcement officers about the average weekly frequency,

duration, and perceived intensity of exercise on a questionnaire. They found that 32% (151 of

470) of officers reported that they performed vigorous exercise at least 20 minutes at least 3

times per week for the last 4 weeks. Remey89

and Franke et al.90

reported that 11% of law

enforcement officers in 9 states (Iowa, Michigan, Minnesota, Missouri, Nebraska, North Dakota,

South Dakota, Ohio, Oklahoma) reported no physical activity in the past month, compared with

28% of the general population in the same states using the same survey question (from the

Behavioral Risk Factor Surveillance Survey).

Table 13. Austin City Police Self -Reported Physical Activity Physical Activity Women (%) (n=80) Men (%) (n=654)

Little or None 4 10

Occasional 58 48

Regular, ≥ 3times/week 39 42

(2) Table 14 shows studies that have examined the association between injuries and prior

physical activity in military groups. All of these studies involved recruits or conscripts in US,

Norwegian, or Danish basic training. All studies used questionnaires that asked individuals to

provide global assessments of their past physical activity. Injury definitions varied widely as

shown in Table 15. Nonetheless, with few exceptions, higher levels of previous physical activity

were associated with lower injury risk and in most investigations there was a dose response


21

relationship: as the amount of previous physical activity increased, injury risk decreased.

Several studies12, 13, 16, 43, 44, 58, 59

used a question developed by Washburn et al. 92

or a

modification of that question, that asking individuals to determine on a 5-point Likert scale how

physically active they were compared with others of their age and sex. In most of the studies

that used that question found that the more physical activity men reported, the less likely they

were to get injured 12, 13, 16, 43, 44, 58

; the studies that asked this question of women showed little

relationship between self-reported physical activity and injuries.13, 16, 32, 58, 59

Most studies12, 32, 56,

58, 59 that asked individuals to self-report their running or exercise frequency showed that as

frequency increased, injuries decreased. Generally, the longer an individual had been running,

the lower the injury risk.12, 32, 56, 58, 59

Table 14. Association between Prior Physical Activity and Injuries in Military Groups Study Subjects Outcome Measure (injury

definition)

Physical Activity Measure and Results

Gardner et al.

198821

3,008 ♂

Marine

Corps

recruits

Stress fractures and stress

reactions

Usual physical activity status (%inj)

Very Active 0.6

Active 0.9

Average 1.6

Below Average 2.0

Inactive 12.0

Jones et al.

199312

303 ♂ US

Army

infantry

recruits

Lower extremity musculoskeletal

injury with a visit to a medical

care provider

1. Self assessed physical activity92 (% inj)

More Active 28.9

Average 50.6

Less Active 46.7

2. Running frequency (%inj)

≥4 days/week 20.0

1-3 days/week 37.6

0-≤1 days/week 43.5

3. Running duration previous month (%inj)

≥60 min/week 25.9

<60 min/week 40.4

None 43.0

Jones et al.

199313

124 ♂ and

186 ♀US

Army

recruits

Musculoskeletal injury with visit

to a medical care provider and 1

more days of limited duty

Self assessed physical activity92 (%inj)

Men Women

Very Active 3.4 30.7

Active 15.7 33.3

Average 35.1 29.7

Less Active 42.7 30.0

Heir & Eide

199743

475-477 ♂

Norwegian

conscripts

Pain, inflammation or functional

disorder involving the

musculoskeletal system or soft

tissue resulting in a visit to a

medical provider

1. Self assessed physical activity92 (inj/100 recruit-months)

More Active 9.9

Average 12.1

Less Active 16.7

2. Hours of weekly physical activity (inj/100 recruit-

months)

>10 hours/week 10.7

3-10 hours/week 12.7

0-2 hours/week 13.9


22

Study Subjects Outcome Measure (injury

definition)


Shaffer et al.

199956

1,286

(Group 1)

and 1,078

(Group 2)

♂ US

Marine

recruits

Stress fractures 1. Frequency of sweating during exercise (% inj)

Group 1 Group 2

All/quite a lot 1.6 1.8

Fairly Often 3.6 5.1

Never/occasionally 8.3 6.2

2. Exercise frequency (%inj)

≤2 time/week 6.9 5.1

3 times/week 3.2 3.2

≥4 times/week 2.6 3.4

3. Months running in past year (%inj)

None 5.7 4.0

≤1 month 5.9 3.7

>3 months 1.6 2.4

2-3 months 2.3 4.4

Knapik et al.

200116

220 ♂ and

184 ♀ US

Army

recruits

Physical damage to the body for

which a medical care provider was

consulted

1. Self assessed physical activity92 (risk ratios & 95%CI)

Men Women

More active 1.0 (referent) 1.0 (referent)

Average 1.0 (0.6-1.9) 1.0 (0.6-1.6)

Less active 1.7 (1.0-2.9) 0.7 (0.4-1.2)

2. Exercise/sports frequency (risk ratios & 95%CI)

<1 time/week 1.8 (1.0-3.1) 0.8 (0.5-1.5)

1 time/week 1.0 (0.5-1.9) 1.0 (0.5-1.8)

≥2 times/week 1.0 (referent) 1.0 (referent)

Rosendal et al.

200344

330 ♂

Danish

Conscripts

Acute injuries – those induced by

sudden, forceful, traumatic events;

overuse – problems of the

musculoskeletal system of

insidious onset associated with

repetitive physical activity

Self assessed physical activity (% inj)

Overuse Inj Acute Inj

Well trained 4.5 10.6

Trained 14.4 9.2

Less trained 27.3 10.2

Untrained 43.5 13.0

Shaffer et al.

200661

2957 ♀ US

Marine

Corps

recruits

Stress fracture 1. Self assessed physical activity (% inj)

Excellent/very good 3.6

Good 4.8

Fair/Poor 6.9

2. Frequency of sweating during exercise (% inj)

Always/quite a lot 4.6

Fairly often 5.0

Never/occasionally 6.0

3. Exercise/sport frequency (% inj)

0-1 day/week 4.8

2-4 days/week 5.3

5-7 days/week 5.0

4. Frequency of running (% inj)

None 7.9

1-3 times/week 5.5

≥4 times/week 3.8

5. Duration of running (% inj)

>20 minutes/session 3.7

≤20 minutes/session 5.3


23


definition)


Rauh et al.

200632

824 ♀ US

Marine

Corps

recruits

Lower extremity stress fracture or

non-stress fracture overuse injury

1. Frequency of sweating during exercise (% inj)

Stress Fx Non-stress Fx Inj

Always/quite a lot 5.6 37.9

Fairly often 7.3 46.8

Never/occasionally 7.8 41.1

2. Exercise frequency (%inj)

5-7 times/week 4.9 39.2

2-4 times/week 6.7 42.6

0-1 time/week 12.1 43.9

4. Running frequency

≥4 times/week 5.9 39.0

1-3 times/week 7.2 42.8

Nonrunner 7.3 43.6

5. Months running in past year (%inj)

≥7 months 4.3 36.4

0-6 months 7.5 43.1

Knapik et al.

200958

2,144 ♂

and 915 ♀

US Army

recruits

ICD-9 codes indicative of overuse

or traumatic injury

1. Self assessed physical activity92 (hazard ratio, 95%CI)

Men Women

Much more active 1.0 (referent) 1.0 (referent)

More active 1.0 (0.7-1.3) 1.1 (0.7-1.7)

Average 1.1 (0.8-1.5) 1.2 (0.7-1.8)

Less active 1.2 (0.9-1.6) 1.5 (0.9-2.0)

Much less active 1.7 (1.2-2.4) 1.5 (0.9-2.4)

2. Exercise/sports frequency (hazard ratio, 95%CI)


2-4 times/week 1.0 (0.9-1.3) 1.1 (0.9-1.4)

≤1 time/week 1.3 (1.0-1.6) 1.4 (1.1-1.8)

3. Running/jogging frequency (hazard ratio, 95%CI)


2-4 times/week 1.0 (0.8-1.3) 1.3 (0.9-1.9)

≤1 time/week 1.3 (1.0-1.7) 1.6 (1.2-2.3)

4. Length of time running/jogging (hazard ratio, 95%CI)

≥7 months 1.0 (referent) 1.0 (referent)

4-6 months 1.2 (0.9-1.8) 1.1 (0.7-1.6)

2-3 months 1.1 (0.9-1.5) 0.9 (0.7-1.3)

≤1 month 1.1 (0.8-1.5) 1.2 (0.9-1.6)

None 1.6 (1.2-2.1) 1.3 (1.0-1.9)


24


definition)


Knapik et al.

201059

1,432 ♂and

509 ♀ US

Air Force

recruits

ICD-9 codes indicative of overuse

or traumatic injury

1. Self assessed physical activity92 (hazard ratio, 95%CI)

Men Women

Much More Active 1.0 (referent) 1.0 (referent)

More Active 0.8 (0.6-1.1) 0.9 (0.5-1.6)

Average 1.0 (0.8-1.4) 1.2 (0.7-2.0)

Less Active 0.9 (0.6-1.4) 1.1 (0.6-1.8)

Much Less Active 1.1 (0.7-1.9) 1.2 (0.6-2.3)

2. Frequency of exercise/sports (hazard ratio, 95%CI)


2-4 times/week 1.0 (0.8-1.3) 1.2 (0.9-1.8)

≤1 time/week 0.9 (0.6-1.2) 1.2 (0.8-1.9)

3. Frequency of running/jogging (hazard ratio, 95%CI)


2-4 times/week 1.1 (0.8-1.6) 1.4 (0.9-2.3)

≤1 time/week 1.0 (0.7-1.4) 1.7 (1.0-2.8)

4. Length of time running/jogging (hazard ratio, 95%CI)

≥7 months 1.0 (referent) 1.0 (referent)

2-6 months 1.1 (0.8-1.6) 1.6 (1.0-2.7)

≤1 month 1.2 (0.8-1.7) 1.6 (1.0-2.6)

Legend: ICD-9=International Classification of Diseases, Revision 9; 95%CI=95% confidence interval; US=United

States; %inj=percent injured; inj=injury; Fx=fracture

(3) In contrast to studies on prior physical activity, other studies have shown that as the

amount of current physical activity increases, so does injury incidence. Studies have been

conducted largely among runners82, 86, 93-99

but also among athletic club members,100

military

recruits,12, 31, 101

combinations of runners and walkers,83-85, 87

and participants in sports and other

leisure-time activity.102, 103

Most of these investigations have used self-reports of injuries and

physical activity, although a few studies have documented injuries from medical records,12, 31, 101

obtained physical activity from training logbooks,12, 31, 97

or from direct pedometer

measurements.101

e. Associations between Tobacco Use and Injuries.

(1) No studies were found on the association between cigarette smoking and injuries in

law enforcement officers. However, several studies report on the prevalence of cigarette

smoking among law enforcement officers. Obtaining prevalence data is complicated by different

definitions of smokers and temporal trends in cigarette smoking. Cigarette smoking has declined

in the United States over the years 1974 to 1985104

; more recently (1993-2004), smoking

continued to decline among heavy smokers but not among occasional smokers. 105

(2) Several studies that include smoking prevalence data on law enforcement officers

found that 12% to 52% were smokers. Sparrow et al.106

defined cigarette smoking as men who

smoked one or more cigarettes/day and found in 1963 that among 220 police officers in the

Boston area, 52% were smokers, compared with 50% among 1428 civilians. Young and


25

Steinhardt88

collected data in 1990-1991 and found that 12% of law enforcement officers in the

city of Austin, Texas, reported that they currently smoked cigarettes. Franke et al.90

and

Ramey89

reported in a 1999 survey of officers in nine upper mid-West states that 36% of officers

smoked daily in the past 5 years compared with 28% of individuals in the general population. In

a sample of 171 male police officers (presumably from Omaha, Nebraska) 22% were smokers,

although no definition of smoking was provided.107

(3) Despite the lack of data for law enforcement officers, an extensive literature in the

military and civilian sector has documented that cigarette smoking is associated with injuries.

Cigarette smoking prior to basic training has consistently been associated with increased injury

risk in Army and Air Force basic training12, 16, 22, 23, 108, 109

and in Army basic training in other

countries.43, 110

Further, smoking was associated with injury in infantry soldiers71

and in other

occupational groups.77, 111-117

Studies showing associations between smoking and injuries in

military groups are shown in Table 15.

(4) With regard to the possible mechanisms and the biological plausibility of the

association between injury risk and cigarette smoking, there is considerable literature showing

associations between smoking, injuries, and psychosocial factors,118-121

as well as studies

showing that cigarette smoking impairs wound healing,122-126

bone healing,127-131

tissue

strength,132-137

, and immune function. Mechanisms to explain the association between cigarette

smoking and injuries have been detailed elsewhere.22

Table 15. Association between Cigarette Smoking and Injuries in Military Studies Study Subjects Outcome Measure (injury definition) Cigarette Smoking Measure and Results

Jones et al.

199312

299 ♂ US

Army infantry

recruits

Lower extremity musculoskeletal injury

with a visit to a medical care provider

Cig/day in last month (% inj)

None in Last Year 29.7

None in Last Month 36.7

1-9 cig/day 34.5

10-19 cig/day 52.8

≥20 cig/day 49.2

Reynolds et al.

199471

181 US ♂

Infantry

Soldiers

Clinic visit for a training-related

musculoskeletal injury

Cig/day in last year (% inj)

None 37.0

1-10 cig/day 59.2

>10 cig/day 64.0

Heir & Eide

199743

480 ♂

Norwegian

conscripts

Pain, inflammation or functional

disorder involving the musculoskeletal

system or soft tissue resulting in a visit

to a medical provider

Cig/day in last month (inj/100 recruit-months)

None 10.7

1-10 cig/day 11.4

≥11 cig/day 16.3

Reynolds et al.

2000138

239 US

Marines in a

winter

training

exercise

Cold injuries-frostnip, frostbite,

chilblains

Cig/day in last year (odds ratios & 95%CI)

Nonsmoker 1.0 (referent)

1-10 cig/day 1.9 (0.5-7.1)

11-20 cig/day 3.5 (0.7-18.6)

>20 cig/day 19.7 (1.8-212.6)


26

Study Subjects Outcome Measure (injury definition) Cigarette Smoking Measure and Results

Altarac et al.

2000108

1089 ♂ and

915 ♀ US

Army recruits

Overuse injuries resulting in a visit to a

medical care provider

Smoked cig in last month (% inj)

Men Women

No 24 40

Yes 32 51

Knapik et al.

200116

166 ♂ and

146 ♀ US

Army recruits

Physical damage to the body for which

the Soldier sought medical care

Cig/day in last year (risk ratios & 95%CI)

Men Women

Never 1.0 (referent) 1.0 (referent)

<11 cig/day 1.6 (0.7-3.9) 1.7 (0.8-3.3)

11-20 cig/day 2.0 (0.9-4.1) 1.8 (0.9-3.5)

≥21 cig/day 2.8 (1.4-5.6) 4.4 (1.9-10.0)

Knapik et al.

200930

821 ♂ and

566 ♀US

Marine Corps

recruits

ICD-9 codes indicative of overuse or

traumatic injury

1. Smoked in last 30 days (hazard ratio & 95%CI)

Men Women

No 1.00 (referent) 1.00 (referent)

Yes 1.26 (1.02-1.57) 1.17 (0.87-1.58)

2. Cig/day in last 30 days (hazard ratio & 95%CI)

None 1.00 (referent) 1.00 (referent)

1-9 cig/day 1.26 (0.98-1.61) 1.07 (0.76-1.50)

≥10 cig/day 1.28 (0.93-1.76) 1.57 (0.94-2.63)

Wilkerson et

al.200976

644 ♂ British

Infantry

Soldiers

Physical damage to the body for which

the Soldier sought medical care in a

one-year period

1. Smoked in last 30 days (hazard ratio & 95%CI)

No 1.00 (referent)

Yes 1.12 (0.91-1.37)

2. Cig/Day in Last 30 Days

None 1.00 (referent

1-9 cig/day 1.14 (0.84-1.54)

10-20 cig/day 1.14 (0.91-1.43)

21-50 cig/day 0.76 (0.36-1.62)

Knapik et al.

200958

2,147 ♂ and

915 ♀ US

Army recruits


traumatic injury


Men Women


1-19 cig/day 1.20 (1.01-1.42) 1.44 (1.19-1.73)

10-19 cig/day 1.24 (1.01-1.42) 1.49 (1.17-1.89)

≥20 cig/day 1.67 (1.31-2.13) 1.90 (1.34-2.68)

2. Days smoked in last 30 days (hazard ratio & 95%CI)


1-9 days 0.97 (0.76-1.25) 1.21 (0.91-1.61)

10-19 days 1.14 (0.87-1.50) 1.57 (1.12-2.20)

≥20 days 1.42 (1.22-1.65) 1.58 (1.32-1.88)

Knapik et al.

201059

1,450 ♂ and

514 ♀ US Air

Force recruits


traumatic injury

1. Smoked cig in last 30 days (hazard ratio & 95%CI)

Men Women

No 1.00 (referent) 1.00 (referent)

Yes 1.41 (1.14-1.74) 1.30 (0.97-1.74)



1-9 days 1.29 (1.00-1.67) 1.50 (1.05-2.51)

≥10 days 1.47 (1.09-1.99) 1.49 (0.98-2.27)

Abbreviations: ICD-9=International Classification of Diseases, Revision 9; 95%CI=95% confidence interval;

US=United States; %inj=percent injured; inj=injury; cig=cigarettes


27

f. Exertional Rhabdomyolysis.

(1) Rhabdomyolysis is defined as physical damage to striated muscle fibers due to

mechanical or metabolic stress that results in the release of muscle cell contents into the

circulation. These muscle cell contents may include (but are not limited to) creatine kinase

(CK), myoblobin, calcium, potassium, organic acids and proteases. Rhabdomyolysis can be

induced by direct physical trauma such as a crushing injury, thrombosis, or electrical shock. It is

common in individuals who have metabolic myopathies related to the inability to deliver

adequate energy to the muscles (e.g., McArdles disease [inability to utilize muscle glycogen],

carnitine palmitoyl transferase deficiency, and phosphofructokinase deficiency). It can be

induced by certain drugs or toxins and local invasive infections of muscle may cause it.

(2) Exertional rhabdomyolysis (ER) refers to damage to skeletal muscle induced by

excessive physical activity in otherwise healthy individuals. In ER, individuals presumably

perform so much activity that they deplete local muscle energy stores. As a result of energy

depletion, myocytes are unable to maintain cellular integrity, resulting in cell damage and the

release of cellular contents.139-141

(3) In ER, the precipitating event is physical activity in excess of that to which the

individual is accustomed. There are numerous case reports of ER in the literature associated

with military training,142-149

but also cases during police recruit training150, 151

, in testing of

firefighter candidates,150

in swim training,152

in bodybuilding,153, 154

among prison inmates,155

in

school children,156

and even cases involving personal trainers.157

Outbreaks involving multiple

individuals participating in exercise events have occurred in police,150

military,144, 147, 149

athletic

training,152

and in high school physical education.156

Rhabdomyolysis can occur even in trained

athletes if the exercise volume is greater than that normally imposed during training.152-154, 157

(4) Risk factors for ER have not been well investigated but a few studies suggest that low

levels of prior physical activity, low physical fitness, Black race, and warmer weather increases

the likelihood.150, 158

Studies identifying these risk factors examined fire department candidates,

police officer trainees, and military personnel. One outbreak investigation of ER involved

candidates testing for admission into the New York City Fire Department. They took a test that

involved 11 simulated firefighting tasks while wearing a 20-lb vest and 20-lb oxygen tank.

Completion of the tasks in ≤7 minutes was passing and completion in ≤4 minutes provided the

highest score. During a 19-month period in which the test was modified four times, there were a

total of 16,506 candidates and 32 were hospitalized for rhabdomyolysis (CK ≥600 U/L) or renal

impairment (serum creatine ≥3.0 mg/dl). This provided an incidence of 0.2% (32/16,506). Risk

was lower among those engaging in prior physical activity (work plus leisure physical

activity≥50 hours/week) (OR=0.2, 95%CI=0.1-0.9).150


28

(5) Another outbreak investigation involved 50 police trainees in Western Massachusetts

who were involved in a “mental stress test” (not defined in article) and physical training

program. The first 3 days of the program involved heavy physical activity (push-ups, squat

thrusts, and running) and hydration was likely not adequate during this time. By the third day, 5

trainees had been hospitalized. All 50 trainees had serum CKs ≥10 time normal and 33 had CKs

≥200 times normal (the latter defined a severe rhabdomyolysis). Thirteen of the trainees were

eventually hospitalized with CKs ≥32,000 U/L and abnormal urinalysis. Nine of the hospitalized

group had serum creatinine ≥ 2.0 mg/ml (defined as renal insufficiency). One trainee died 44

days after onset. One month before the program 49 trainees were administered a 1.5-mile run

and sit-up test. Compared to trainees who passed both fitness tests (passing criteria not

provided), those who failed either test were at 2.5 times (95%CI=1.3-4.9) higher risk of severe

rhabdomyolysis, and 2.0 times (95%CI=0.5-8.8) higher risk of renal insufficiency.150

(6) Cases of ER were investigated in the military services from 2004 to 2007 using

medical surveillance data. ER was defined as an International Classification of Diseases,

Version 9, Clinical Modification (ICD-9-CM) code of 728.88 (rhabdomyolysis) and/or 791.3

(myoglobinuria), plus a diagnosis of 276.5 (volume depletion (dehydration)), and/or 992.0-992.9

(effects of heat) and/or 994.3-994.5 (effects of thirst (deprivation of water), exhaustion due to

exposure, and exhaustion due to excessive exertion (overexertion)). The year 2004 was the first

year that the ICD-9-CM code for rhabdomyolysis was available. There were 595 incidence cases

of presumed ER. Those of “Black, non-Hispanic” race and “other” race were at increased risk

relative to “White, non-Hispanics”. Eighty four percent of cases occurred in the June to

September months (mid to late summer). Thirty seven percent of cases occurred at 9 military

bases conducting basic military training.158

(7) Diagnosis of ER is based on clinical examination and laboratory finding. Patients

typically present with a history of heavy and unaccustomed exercise and with symptoms of

severe muscle pain, muscle swelling, weakness, and decreased range of motion. The urine may

be dark brown. Pain is often localized to the muscle groups that were excessively exercised.

Suggested diagnostic criteria for ER have been developed by the Uniformed Services University

Consortium for Health and Military Performance in conjunction with the Israeli Defense Force’s

Heller Institute. These criteria are 1) a serum CK level five times higher than the upper limit of

normal and/or, 2) a urine dipstick positive for blood (due to the presence of myoglobin), but

lacking red blood cells under microscopic urinalysis.159

Two distinct subgroups of ER have been

suggested by the consortium. These subgroups are 1) physiologic (benign) ER and 2) clinically

relevant ER. Physiological ER is defined as a patient with elevated CK but no other signs or

symptoms beyond mild muscle pain expected for the circumstances. This is essentially delayed

onset muscle soreness. In clinically relevant ER, the patient presents with severe muscle pain,


29

muscle swelling, muscle weakness, and myoglobinuria along with the other diagnostic criteria.159

It is likely that these distinctions are “points” on a continuum ranging from mild to severe muscle

damage.

(8) Medical management of ER involves aggressive hydration and correcting electrolyte

imbalances. Aggressive hydration replaces fluids that may have been sequestered into the

damaged myocytes (as a result of the failure of energy-dependent transcellular pumps) and

reduces the probability of acute renal failure by increasing urine flow to assist in removal of

myoglobin. Acute renal failure is the most serious complication of rhabdomyolysis and is

thought to be due to free myoglobin, which may cause renal vasoconstriction and nephrotoxic

effects and/or precipitate to produce renal tubular obstructions (pigmented “casts”). To

minimize the possibility of acute renal failure, urine output should be >300 ml/h and urine

pH>7.5. Diuretics (e.g., furosemide, mannitol) may be used if necessary to maintain urinary

output. Mannitol which increases renal blood flow and glomerular filtration rate, is an osmotic

agent that extracts fluids from interstitial compartments (thus reducing hypovolemia, muscle

swelling, and nerve compression), and increases urinary flow (reducing myoglobin

precipitation). Urine can be alkalinized by the addition of 50-100 mEq of sodium bicarbonate to

each liter of administered fluid. The proposed ideal fluid regimen is half isotonic saline (0.45%

sodium), to which 75 mmoles/l sodium bicarbonate is added. Although mannitol and

bicarbonates are the standard of care for reducing the likelihood of acute renal failure, some

studies suggest that their use provides no additional benefit to patients over aggressive hydration

with saline alone. Blood urea nitrogen and creatinine can be monitored to indicate renal

function. Attention should be directed to monitoring potassium, calcium and phosphate levels to

correct hyperkalemia, hypocalcemia, and hypophosphatemia when present. Hyperkalemia and

hypophosphatemia result from direct release of potassium and phosphates from muscles.

Hypocalcemia is from the buildup of calcium in muscle due to the failure of sodium-calcium

exchange.139-141, 155, 160-163

Recommendations for return to activity have also been proposed.159

Rehabilitation following the acute phase of ER can be prolonged and a rehabilitation program

has been described.144, 164

(9) In cases of ER it may be important for the medical care provider to question the

patient as to whether or not other individuals performed similar activities. This is a common

situation in the military and in some types of FBI new agent training (e.g., point run, physical

fitness testing) where training may involve large groups of individuals. There may be other

individuals with similar symptoms who have not sought immediate medical care.149

(10) Several studies have shown that the exercise-induced rise in serum CK and

myoglobin can be reduced by a period of pre-conditioning prior to more intense physical

training.165, 166

This adaptation may be mediated by a training-induced increase in the size and

number of mitochondria in the myocytes167

that can provide additional ATP to assist in


30

stabilizing cellular walls during exercise. Risk of ER in normal healthy individuals can be

reduced by graded, individual pre-conditioning prior to beginning a more strenuous exercise

regiment and group exercise. In group activity, exercises of specific muscle groups (common in

calisthenics type exercises) should be introduced gradually starting with only a few repetitions,

and emphasizing the correct form. Sudden increases in exercise volume should be avoided. Rest

and rehydration should be emphasized during training, especially in higher temperatures. Rest

and rehydration schedules have been developed for the military and are included in Table 16.

Table 16. Military Fluid and Work Rest Guidelines (WBGT=Wet Globe, Bulb Temperature)

Heat

Level

WBGT

(OF)

Easy Work Moderate Work Hard Work

Work/

Rest

(min)

Water

Intake

(qt/h)

Work/

Rest

(min)

Water

Intake

(qt/h)

Work/

Rest

(min)

Water

Intake

(qt/h)

1 78-82 No

Limit

0.5 No

Limit

0.75 40/20 0.75

2 82-85 No

Limit

0.5 50/10 0.75 30/30 1.0

3 85-88 No

Limit

0.75 40/20 0.75 30/30 1.0

4 88-90 No

Limit

0.75 30/30 0.75 20/40 1.0

5 >90 50/10 1.0 20/40 1.0 10/50 1.0

Montain, Milit Med 164:502, 1999

5. METHODS.

a. FBI New Agent Training.

(1) New agent classes at the FBI academy consisted of a maximum of 50 individuals

who together participated in 21 weeks of training. The new agent training curriculum consisted

of over 900 hours of training. This included about 114 hours of firearms training, 94 hours of

defensive tactics training, and about 95 hours of practical application training. Firearms training

included marksmanship (Glock 22, shotgun, MP5, and M-16), close combat skills, and moving

in teams with weapons. Defensive tactics involved boxing, self-defense, and suspect

apprehension techniques. Practical application training included driver training, conducting


31

surveillance, entering and clearing rooms, and arresting suspects. New agents were expected to

perform physical fitness training on their own, although those who failed the first physical fitness

test (PFT) were required to attend group physical training three times per week. These group

sessions were conducted on one morning and two afternoons.

(2) FBI new agent classes were numbered with the fiscal year (FY) of the class start date,

and the numeric sequence of the class during that FY. Thus, Class 09-09 was the 9th

class

conducted in FY 2009. The present project followed 12 classes: Class 09-09 through Class 10-

01. The first class (09-09) began training on 15 March 2009 and completed training on 5 August

2009. The last class (10-01) began training on 26 October 2009 and completed training on 18

March 2010.

b. Project Design. This project employed a prospective cohort design. Early on the third day of

training at the FBI Academy, new agents were informed about the purposes of the investigation.

Those who agreed to participate signed a privacy act statement and completed a questionnaire.

During the time the new agents were at the FBI Academy they completed one or more PFTs and

their scores were obtained. Their injuries were tracked from a database at the FBI Health Clinic,

as described below. The project period was about 1 year (March 2009-March 2010).

c. Questionnaire. The questionnaire completed by new agents asked about previous lifestyle

behaviors including tobacco use, physical activity, self-assessed physical fitness, prior injuries

and (for women) menstrual history. The questionnaire is in Appendix C.

d. Physical Characteristics and Demographics.

(1) On arrival at the FBI Academy, new agents filled out a New Agent Trainee Profile

which asked about demographic information. This form is shown in Appendix D. Data

extracted from this form included FBI field office (processing office), program under which new

agent entered, educational level, marital status, number of children, foreign languages spoken,

military experience, law enforcement experience, and dominate hand.

(2) The Standard Form 88 (SF88, Report of Medical Examination) in the new agent

medical record was used to obtain information on the new agent’s gender, height, weight, race,

and date of birth (for age calculation). With the exception of race, these data duplicated some

self-reported data on the questionnaire so that the data could be compared. Data on the SF88

was collected by contract physicians in offices close to the FBI field offices as part of the

medical examination to determine fitness for duty. The minimum time from the medical

examination to entry into the FBI Academy was about six weeks; the maximum might exceed a

year. The SF88 is shown in Appendix E


32

e. Physical Fitness Data.

(1) Physical fitness test (PFT) data were obtained from an existing database in the

Physical Training Unit of the FBI Academy. The PFT consisted of four scored events: 1-minute

sit-ups, 300-meter run, push-ups to exhaustion, and 1.5-mile run, administered in that order.

Pull-ups to exhaustion were also included, but this event was not considered in the total score.

At least 5 minutes of rest were provided between events. At the start of the project, PFTs were

administered at Weeks 1, 7, and 14 of new agent training. After 3 August 2009, PFTs were

administered at Weeks 1, 9, and 18. New agents who passed the second test were not required to

take the final test.

(2) For the sit-ups, the new agent lay on his/her back with the tops of the shoulder blades

touching the floor. Hands were behind the head with fingers interlaced. The knees were bent at

a 90 degree angle with the feet flat on the floor. A partner held the feet in place with the

partner's hands at the tongue of the trainee's shoes and the partner’s knees on the trainee's toes.

To execute a repetition, the new agent raised his/her upper body until the base of the neck was in

line with the base of the spine (back was perpendicular to the floor). The new agent then

returned to the starting position (i.e., the tops of both shoulder blades must touch the floor) to

complete the repetition. This was a timed, 1-minute continuous motion exercise. The number of

repetitions correctly executed served as the performance score.

(3) The 300-meter sprint took place on a ¼-mile oval track or on a straight road. The

new agent started from a standing position in a small group and ran 300 meters (about 3/4 of one

lap) as fast as possible. The performance score was the time to complete the distance.

(4) For the push-up, the new agent began in the front leaning rest position (i.e. hands on

the floor one to two hand widths beyond the shoulders and elbows pointed away from the body,

arms fully extended, body held straight with the feet no more than three inches apart, and the

toes touching the floor). To execute a repetition, the elbows were flexed, the body was lowered

toward the floor until the upper arms were parallel to the floor (straight line from center axis of

elbow to center axis of shoulder). The new agent completed the repetition by returning to the

starting position. This was a continuous motion exercise with no time limit and the test was

discontinued when the trainee could no longer continue the motion. The number of repetitions

correctly executed served as the performance score.

(5) The 1.5-mile run took place on a ¼-mile oval track. The new agent started from a

standing position in a group and ran the distance around the track as fast as possible. The

performance score was the time to complete the distance.


33

(6) For pull-ups, the new agent grasped a horizontal bar with both hands, palms facing

away (pronated). The starting position was with the arms fully extended beneath the bar, feet

free from touching the ground, and the body motionless. One repetition consisted of raising the

body with the arms until the chin was above the bar, with no swinging and then lowering the

body until the arms were fully extended. The motion was repeated as many times as possible

with no time limit and the number of repetitions served as the event score.

(7) Points were assigned to various levels of performance on each PFT event. Table 17

shows the PFT events and the number of points for each performance level. Passing the test

required a score of 12 points, with at least 1 point on each event.

Table 17. Physical Fitness Test Point Systema

Push-Ups Sit-Ups 300-Meter Run (sec)

Points Men

(reps)

Women

(reps)

Points Men

(reps)

Women

(reps)

Points Men

(sec)

Women

(sec)

-2 <20 <4 -2 <32 <30 -2 >55.0 >67.4

0 20-29 5-13 0 32-37 30-34 0 55.0-52.5 67.4-65.0

1 30-32 14-18 1 38 35-36 1 52.4-51.1 64.9-62.5

2 33-39 19-21 2 39-42 37-40 2 51.0-49.5 62.4-60.0

3 40-43 22-26 3 43-44 41-42 3 49.4-48.0 59.9-57.5

4 44-49 27-29 4 45-47 43-46 4 47.9-46.1 57.4-56.0

5 50-53 30-32 5 48-49 47-48 5 46.0-45.0 55.9-54.0

6 54-56 33-35 6 50-51 49-50 6 44.9-44.0 53.9-53.0

7 57-60 36-38 7 52-53 51-52 7 43.9-43.0 52.9-52.0

8 61-64 39-41 8 54-55 53-54 8 42.9-42.0 51.9-51.0

9 65-70 42-44 9 56-57 55-56 9 41.9-41.0 50.9-50.0

10 ≥71 ≥45 10 ≥58 ≥57 10 <40.9 <49.9

1.5-Mile Run Pull-Ups

Points Men

(min:sec)

Women

(min:sec)

Points Men

(reps)

Women

(reps)

-2 >13:29 >14:59 0 <2 0

0 13:29-12:25 14:59-14:00 1 2-3 1

1 12:24-12:15 13:59-13:35 2 4-5 2

2 12:14-11:35 13:34-13:00 3 6-7 3

3 11:34-11:10 12:59-12:30 4 8-9 4

4 11:09-10:35 12:29-11:57 5 10-11 5

5 10:34-10:15 11:56-11:35 6 12-13 6

6 10:14-9:55 11:34-11:15 7 14-15 7

7 9:54-9:35 11:14-11:06 8 16-17 8

8 9:34-9:20 11:05-10:45 9 18-19 9

9 9:19-9:00 10:44-10:35 10 ≥20 ≥10

10 <9.00 <10:35 a12 points are needed to pass the physical fitness test with at least 1 point on each event. Pull-ups are not counted in

the total point score.


34

f. Final Student Status. Data on final student status were obtained from the Training Director’s

Office at the FBI Academy. The list contained the name of each student who did not graduate

with his/her class, the date they left the course, and the reason for not graduating. If a student

was not on the list, it was assumed that the student had graduated. Students who did not graduate

were listed as either recycle-outs, recycle-ins, conversions, dismissals, or resignations. Recycle-

outs were students who were temporarily removed from their class because they were either

injured to the extent they could not complete training on time or because they required additional

training to pass the course. Recycle-ins were students who were returning to the course after

recycling out. Conversions were students who switched from becoming new agents to the

administrative arm of the FBI. Dismissals were students who were involuntarily discharged

from the FBI. Resignations were students who voluntarily left the FBI.

g. Injury Data.

(1) Medical care providers at the FBI Academy Health Clinic at Quantico, Virginia

routinely entered information on medical encounters into a computerized database called

Medical Data Base (MDB). USAPHC-trained personnel examined each of the new agent’s

medical encounters and determined if the encounter was for an injury (defined below) or for

other medical care. For each injury encounter, extracted information included the name of the

new agent, date of visit, type of visit (new injury visit or follow-up on a previous visit),

diagnosis, anatomical location, activity associated with the injury, and final disposition. If no

final disposition was provided in the record, it was assumed that the new agent was returned to

duty. A “consult” disposition was a referral to another level of care including the FBI Academy

physician or another medical clinic. The format used to extract the injury data and the codes are

in Appendix F.

(2) In addition to the data in the MDB, injury information was also obtained from the US

Department of Labor’s, CA-1 form (Federal Employee’s Notice of Traumatic Injury and Claim

for Continuation of Pay/Compensation). Block 13 on the CA-1 form was used to enhance

information regarding the activity associated with the injury. Block 14 on the CA-1 form was

used to enhance the injury diagnosis and anatomical location. In some cases injuries were found

on the CA-1s that were not listed in the MDB and the CA-1 was the only source of information

for the injury. The CA-1 Form is shown in Appendix G.

(3) An injury case was a new agent who sustained physical damage to the body168

and

sought medical care or medical compensation one or more times during the survey period.

Injuries were grouped by “type” which was determined from descriptive information in the

medical notes and/or CA-1, and by the specific diagnosis. Injury types included 1) overuse

injury, 2) traumatic injury, 3) environmental injury, and 4) any injury. Overuse injuries were

presumably due to or related to prolonged repetitive energy exchanges, resulting in cumulative


35

microtrauma. Specific overuse diagnoses included musculoskeletal pain (not otherwise

specified), tendonitis, bursitis, fasciitis, muscle injury presumably due to overuse (strain), joint

injury presumably due to overuse (sprain), retropatellar pain syndrome, impingement,

degenerative joint conditions, and shin splints. A traumatic injury was presumably due to sudden

energy exchanges (acute event), resulting in abrupt overload with tissue trauma. Specific

diagnoses included pain (due to an acute event), muscle injury due to acute event (strain), joint

injury due to an acute event (sprain), dislocation, fracture, blister, abrasion, laceration,

contusions, and closed head injury/concussion. An environmental injury was presumably due to

exposure to weather, animals, or chemicals, resulting in physical damage to the body.

Environmental injury diagnoses included heat-related injuries, animal bites, chemical exposures,

and exertion (defined below). The “any injury” type included overuse and trauma diagnoses as

described above, but excluded environmental injuries. These consisted primarily of

musculoskeletal injuries, but also included dermatological events (e.g., blisters, abrasions,

lacerations).

(4) Because of the interest in rhabdomyolysis cases these were defined separately. To be

classified as rhabdomyolysis, the medical record had to state “rhabdomyolysis” or “possible

rhabdomyolysis”, and/or report a CK level exceeding 1,000 U/L.

(5) “Exertion” was defined as an event resulting in the inability to continue physical

activity after a strenuous activity bout in conjunction with a medical encounter. This was

generally coded as “exertion” in the medical record. Although inability to continue physical

activity was the primary and defining symptom, additional symptoms might include syncope,

lightheadedness, nausea, and vomiting. While exertion is not an injury as defined above,

exertion-related events were included in the analysis because they may be related to physical

fitness and, possibly, rhabdomyolysis.

(6) New injuries were first medical encounters with a patient resulting in a particular

diagnosis at a particular anatomical location. Follow-up injuries were subsequent medical

encounters for the same injury. If follow-up visits occurred, they were used in conjunction with

the initial encounter to determine the final diagnosis for a specific injury. Thus, an initial

diagnosis could be changed as a result of a more specific diagnosis at a higher level of medical

care.

h. Data Analysis.

(1) Six databases were compiled and merged using Excel 2007 and Predictive Analytic

Software (PASW), Version 18.0.0. These were data from the 1) questionnaires, 2) New Agent

Trainee Profiles, 3) SF88s (demographics from the medical records), 4) physical fitness tests, 5)

MDB (injury data), and 6) final student status.


36

(2) All analyses were performed with PASW, Version 18.0.0. Descriptive statistics

(frequencies and percentages) were calculated for student status, injury diagnoses, injury

anatomical locations, activities associated with the injury, and final dispositions. For all injury

types (any injury, overuse injury, traumatic injury and environmental/other injury), injury

incidences were calculated as:

[(new agent trainees with ≥ 1 injury) (total number of new agent trainees)] 100%.

Injury incidence rates for all injury types were calculated as:

[(new agent trainees with ≥ 1 injury) (total number of days in training)] 1000.

(3) Descriptive statistics were also calculated for all other variables. For discrete,

nominal, and ordinal variables, frequencies and percentages were calculated. For continuous

variables, means and standard deviations (SDs) were calculated. To make comparisons among

groups with discrete, nominal, or ordinal variables, the chi-square statistic was used. To make

comparisons among groups with continuous variables, t-tests or analysis of variance were used.

(4) Cox regression (a survival analysis technique) was used to examine the association

between the time to the first injury (any injury) and independent variables (potential injury risk

factors) from the questionnaires, New Agent Trainee Profiles, SF88s, and physical fitness tests.

For each analysis, once a subject had an injury, his or her contribution to time in new agent

training was terminated. Those who attrited from training had their time censored (i.e., end of

time at risk) at the day they left training. All variables were entered into the regression models

as categorical variables. Continuous variables were converted to quartiles (four groups of about

equal size) or tertiles (three groups of about equal size) based on the distribution of scores. Some

nominal and ordinal variables were combined to increase statistical power. Age was categorized

into two groups, above and below 30 years of age. For all Cox regressions, simple contrasts

were used, comparing the hazard at a baseline level of a variable (defined with a hazard ratio

(HR) of 1.00) with other levels of the same variable. Univariate Cox regressions established the

individual association between time to first injury and levels of each variable. Variables were

included in a multivariate Cox regression if they achieved p< 0.10 in the univariate analyses.169

Multivariate Cox regressions established the effect of multiple risk factors on injury risk.


37

6. RESULTS.

a. New Agent Classes and Final Student Status.

(1) Table 18 shows the number of new agents in each of the classes who were involved in

the project. A total of 531 new agents enrolled in the project, 426 men and 105 women. Three

new agents declined to participate.

Table 18. Dates and Numbers of New Agents Enrolled By Class

Date of Briefing and

Questionnaire

Administration

Date Class

Started

Date Class

Graduated Class

Number

Number of

New Agents Enrolled

New Agents

Who

Declined

Participation Men Women

19MAR09 16MAR09 5AUG09 09-09 34 8 0

1APR09 30MAR09 19AUG09 09-10 30 11 0

15APR09 13APR09 2SEP09 09-11 36 7 0

29APR09 27APR09 17SEP09 09-12 35 8 0

28MAY09 25MAY09 16OCT09 09-13 39 11 0

10JUN09 8JUN09 29OCT09 09-14 37 10 0

8JUL09 6JUL09 27NOV09 09-15 33 16 0

22JUL09 20JUL09 11DEC09 09-16 31 5 2

5AUG09 3AUG09 28DEC09 09-17 32 4 0

2SEP09 31AUG09 27FEB10 09-19 37 9 1

16SEP09 14SEP09 9FEB10 09-20 39 10 0

28OCT09 27OCT09 18MAR10 10-01 43 6 0

(2) Table 19 shows the number and percentages of students who did and did not complete

the new agent course the first time in training. The table also shows recycles, conversions,

dismissals and resignations. Recycle-outs presumably entered another class at a later date but

were not followed once they left their initial class. Six of the seven students who recycled in

were all present at the start of training and all completed the training with the first class they

entered during this project. One of the female recycle-in recycled out a second time.

Table 19. New Agents Completing and Not Completing Training Men Women

N %

Completed Training First Time 376 88.3 70 66.7

Did Not Complete Training First Time 50 11.7 35 33.3

Recycles Out 33 7.7 31 29.5

In 4 0.9 3 2.7

Conversions 9 2.1 2 1.9

Dismissals 2 0.5 2 1.9

Resignations 6 1.4 1 1.0


38

(3) Table 20 shows the proportion of new agents who did not complete training because

of injuries, physical fitness, and for other reasons. For the men, 3.1%, 1.6% and 3.1% were

recycled for injuries, physical fitness and other reasons, respectively. For women, 4.8%, 1.0%

and 23.8% were recycled for injuries, physical fitness, and other reasons, respectively.

Table 20. New Agent Reasons for Not Completing Training (number of new agents) Men Women

Recycles Conversion Dismissals Resignations Recycles Conversion Dismissals Resignations

Injury 13 0 0 0 5 0 0 0

Physical Fitness 7 1 0 0 1 0 0 0

Other Reasons 13 8 2 6 25 2 2 1

b. Descriptive Data on Injuries.

(1) Table 21 shows the number of new injury cases and injury follow-ups by diagnosis.

In 28 new injury cases (9% of all cases), injury information was obtained from the CA-1s only

(i.e., not from the MDB). Among new injuries, overuse injuries made up 14% of cases while

traumatic injuries made up 68% of cases. The diagnoses with the largest number of new injury

cases were traumatic sprains (joint injuries), traumatic strains (muscle injuries), and

musculoskeletal pain associated with trauma. These three diagnoses accounted for 38% of all

new injury cases. Diagnosis of musculoskeletal pain were medical encounters during which an

individual reported pain in a specific musculoskeletal location from a traumatic event but no

specific diagnosis was found in the record. Among follow-ups for injuries, traumatic sprains

(joint injuries), traumatic strains (muscle injuries) and musculoskeletal pain associated with

trauma accounted for 48% of all follow-ups.


39

Table 21. New Agent Injury Cases by Diagnoses Type Diagnosis New Injuries Follow-Ups

N % N %

OV

ER

US

E

Tendonitis 10 3.2 3 6.8

Bursitis 2 0.6 0 0.0

Retropatellar pain syndrome 5 1.6 2 4.5

Muscle injury (overuse) 14 4.4 2 4.5

Neurological 1 0.3 0 0.0

Joint injury (overuse) 4 1.3 1 2.3

Musculoskeletal pain (overuse) 6 1.9 0 0.0

Shin splints 1 0.3 0 0.0

TR

AU

MA

TIC

Muscle injury (traumatic) 39 12.4 5 11.4

Joint injury (traumatic) 45 14.3 13 29.5

Musculoskeletal pain (traumatic) 37 11.7 3 6.8

Dislocation 7 2.2 0 0.0

Bone Fracture 4 1.3 2 4.5

Tooth Fracture 2 0.6 0 0.0

Nasal Fracture 2 0.6 0 0.0

Abrasion or laceration 33 10.5 2 4.5

Contusion 33 10.5 4 9.1

Closed Head Injury/Concussion 11 3.5 4 9.1

EN

VIR

/

OT

HE

R General heat-related injury 3 1.0 2 4.5

Exertion 11 3.5 0 0.0

Insect bites or stings 33 10.5 1 2.3

Chemical Burn (OC Spray) a 12 3.8 0 0.0

Total Cases 315 100.0 44 100.0 aOC=oleoresin capsicum

(2) Table 22 shows the number of new injury cases and follow-ups by anatomical

location. Among the new injuries, the head accounted for 19% of cases, the upper body 43% of

cases, and the lower body 31% of cases. Among new injury cases, most common anatomical

sites of injuries in rank order by number of cases were the knees, eyes, shoulders, fingers,

face/lower back, and head. Many of the injuries to eyes were chemical irritation from oleoresin

capsicum spray. Among the follow-up cases, the head accounted for 16% of encounters, the

upper body 36% of encounters, and the lower body 41% of encounters. Among the follow-up

cases, the most common anatomical sites in rank order by number of cases were the ankles,

shoulders, head/fingers/knee.


40

Table 22. New Agent Injury Cases by Anatomic Location Region Anatomic Location New Injuries Follow-Ups

N % N %

Head Head 16 5.1 4 9.1

Face 18 5.7 0 0.0

Ear 2 0.6 2 4.5

Eye 25 7.9 1 2.3

Upper

Body

Neck 13 4.1 1 2.3

Chest 12 3.8 3 6.8

Abdomen 3 1.0 0 0.0

Upper back 1 0.3 0 0.0

Lower back 18 5.7 1 2.3

Shoulder 24 7.6 6 13.6

Elbow 13 4.1 0 0.0

Upper arm 3 1.0 0 0.0

Lower arm 4 1.3 1 2.3

Wrist 7 2.2 0 0.0

Hand 13 4.1 0 0.0

Finger 23 7.3 4 9.1

Lower

Body

Pelvic region 5 1.6 0 0.0

Hip 6 1.9 0 0.0

Posterior thigh (hamstring) 9 2.9 1 2.3

Anterior thigh (quadriceps) 15 4.8 3 6.8

Knee 31 9.8 4 9.1

Calf 6 1.9 0 0.0

Shin 3 1.0 0 0.0

Ankle 15 4.8 9 20.5

Foot 5 1.6 0 0.0

Toe 2 0.6 1 2.3

Other Multiple 1 0.3 0 0.0

Not applicablea 14 4.4 2 4.5

Unknown 8 2.5 1 2.3 Total Cases 315 100.0 44 100.0 aHeat injuries and exertion

(3) Table 23 shows the number of new injuries and follow-ups by the training activity

associated with the injury. Two activities, defensive tactics and physical fitness training, were

associated with 78% of the new injury cases and 86% of the follow-up cases.


41

Table 23. New Agent Injury Cases by Associated Training Activity Activity New Injuries Follow-Ups

N % N %

Defensive Tactics 184 58.4 25 56.8

Physical Fitness Training 63 20.0 13 29.5

Physical Fitness Testing 15 4.8 2 4.5

Firearms Training 8 2.5 0 0.0

Off-Duty, Academy 1 0.3 0 0.0

Off Duty, Not Academy 6 1.9 0 0.0

Operational Skills Training 5 1.6 1 2.3

Sports 1 0.3 0 0.0

Other 6 1.9 0 0.0

Unknown 26 8.2 3 6.8

Total 315 100.0 44 100.0

(4) To further investigate which of the defensive tactics activities was associated with

injuries, the notes extracted from the medical records were examined in more detail. In 20% of

the defensive tactics cases Bull-in-the-Ring was listed as the activity associated with the injury

(n=37). Boxing was listed in 13% of the cases (n=24). Oleoresin capsicum spray was listed in

8% of cases (n=15). Wrestling and groundfighting were each listed in 6% of cases (n=11 for

each). Breakfalls were listed in 3% of cases (n=6). These activities accounted for 56% of the

defensive tactics cases but this is unlikely to be the full picture because in 30% of cases (n=56)

only “defensive tactics” was noted without any other information. (Bull-in-the-Ring is an

activity in which one individual [the “bull”] is surrounded in a circle by about 10 others. An

individual from the outer circle enters the center and for 20-seconds, the “bull” boxes vigorously

with this individual. Once the 20 seconds is up, the individual boxing the “bull” returns to the

outer circle and another individual from the outer circle enters the center and immediately begins

boxing with the “bull”. This continues until all 10 or so individuals from the circle have boxed

with the “bull”. At that point, another individual from the outer circle enters the center and

becomes the “bull” and the process is repeated until all 10 individuals have been the “bull”.)

(5) To investigate which of the physical training activities were associated with the largest

number of injuries, the notes extracted from the medical records were examined in more detail.

In 21% of physical training cases the point run was listed as the activity associated with the

injury (n=13). In 17% of the cases, running was listed (n=11). In 10% of the cases, sprinting

was listed (n=6). In 8% of cases insect bites were listed (n=5). In 6% of the cases, knuckle

push-ups were listed (n=4). These activities accounted for 62% of the physical training- related

injury cases.

(6) To investigate which of the 8 firearms activities were associated with injuries we

examined these separately. There were 2 contusions, one from a weapons recoil and another

unspecified (i.e., only “firearms” was listed in the medical records). There were two tick bites

from firing range activities. There was one shoulder strain acquired when firing from the prone


42

position, one ankle sprain was associated with “going prone at the 25 yard line”, 1

musculoskeletal pain “from moving in and out of various positions”, and 1 exertion-related

event.

(7) Table 24 shows the number of new injury and follow-ups cases by the final

disposition. Among new injury cases, the disposition was return to duty or a consult in 88% of

cases. Among follow-ups the disposition was return to duty or a consult in 70% of cases.

Among follow-ups, the proportion of cases receiving limited duty increased substantially.

Table 24. New Agent Injury Cases by Disposition Activity New Injuries Follow-Ups

N % N %

Return to Duty 211 67.0 24 54.5

Limited Duty 25 7.9 13 29.5

Consult 65 20.6 7 15.9

Hospitalized 0 0.0 0 0.0

Other/Unknown 14 4.4 0 0.0

Total 315 100.0 44 100.0

c. Injury Incidence and Injury Rates.

(1) Table 25 shows injury incidence by gender and type. Overall injury incidence (any

injury) was slightly higher among the women accounted for by higher incidence of both overuse

and traumatic injuries. There were 11 exertion-related events, 10 among the men and 1 among

the women.

Table 25. New Agent Injury Incidence by Gender and Type Injury Type Injury Incidence (%) Risk Ratio – Women/Men

(95% Confidence Interval)

p-valuea

Men Women

Any 35.0 41.9 1.20 (0.93-1.55) 0.19

Overuse 5.6 13.3 2.36 (1.27-4.42) <0.01

Traumatic 31.2 37.1 1.19 (0.90-1.58) 0.25

Exertion 2.3 1.0 0.40 (0.05-3.13) 0.37 aChi-square statistic

(2) Injury incidence rates take into account the time each new agent was involved in

training, i.e., time at risk. The men had an average±SD 137±27 days in training while the

women had 130±29 days. The total days of training were 58,550 for the men and 13,680 for the

women. Table 26 shows the injury incidence rates for men and women and compares them. In

consonance with the injury incident results in Table 25, the overall injury incidence rate (any

injury) was slightly higher among the women; rates were higher among women for both overuse

and traumatic injuries.


43

Table 26. New Agent Injury Incidence Rates by Gender and Type Injury Type Injury Incidence Rates

(injuries/1,000 person-days)

Rate Ratio – Women/Men

(95% Confidence Interval)

p-valuea

Men Women

Any 2.54 3.22 1.26 (0.90-1.77) 0.09

Overuse 0.41 1.02 2.50 (1.29-4.83) <0.01

Traumatic 2.27 2.85 1.26 (0.88-1.79) 0.11

Exertion 0.17 0.07 0.43 (0.05-3.34) 0.20 aChi-square statistic

d. Descriptive Statistics on Physical Characteristics, Demographics, and Questionnaire

Variables.

(1) Tables 27 shows the age and physical characteristics of the new agents obtained from

the questionnaire, trainee profile, and SF88. While Table 27 shows all available data in all 3 data

sets, Table 28 compares the age and physical characteristics data among new agents who had

information in all three data sets (94% of new agents). Age was calculated from date of birth on

the questionnaire and SF88 but reported as an age in years on the trainee profile. It would be

expected that new agents would report being somewhat older in the questionnaire and trainee

profile data because those data were collected later than the medical records data. Men were an

average of 9.7 months older and women were 11.9 months older in the questionnaire data,

compared to the SF88. Average height was about the same in all three sets of data for both men

and women. Men reported slightly less average weight on the questionnaire and Trainee Profile

compared with the SF88, and consequently the calculated average BMI was slightly lower in the

questionnaire and Trainee Profile data. Women’s average weight and BMI was very similar in

all three data sets.

Table 27. New Agent’s Age and Physical Characteristics from Questionnaire, Trainee Profile

and SF88 Where Data

Obtained

Measure Men Women

N Mean±SD N Mean±SD

Questionnaire

(Self-Reported)

Age (years) 426 31.0±3.2 105 30.1±3.1 Height (inches) 426 70.8±2.8 105 65.4±2.7 Weight (pounds) 426 180.3±20.8 105 135.7±17.3 Body Mass Index (kg/m2) 426 25.3±2.4 105 22.3±2.2

Trainee Profile

(Self-Reported)

Age (years) 424 30.4±3.2 104 29.6±3.1 Height (inches) 424 70.9±2.6 104 65.4±2.7 Weight (pounds) 423 180.7±20.8 104 135.7±17.5 Body Mass Index (kg/m2) 423 25.3±2.3 104 22.3±2.2

SF88 Age (years) 405 30.1±3.3 99 29.1±3.1 Height (inches) 404 70.8±2.6 99 65.7±2.8 Weight (pounds) 403 182.6±22.4 99 136.8±18.6 Body Mass Index (kg/m2) 403 25.6±2.6 99 22.2±2.2


44

Table 28. Comparison of Age and Physical Characteristics of New Agents from Questionnaire,

Trainee Profile, and SF88 Measure Men (n=400-402) Women (n=98)

Mean±SD

Questionnaire

Mean±SD

Trainee

Profile

Mean±SD

SF88

p-

valuea

Mean±SD

Questionnaire

Mean±SD

Trainee

Profile

Mean±SD

SF88

p-

valuea

Age (years) 30.9±3.2 30.9±3.2 30.1±3.3 <0.01 30.1±3.1 29.6±3.1 29.1±3.1 <0.01

Height (inches) 70.8±2.7 70.9±2.6 70.8±2.6 0.27 65.4±2.7 65.5±2.7 65.7±2.8 0.06

Weight (pounds) 180.4±21.0 180.8±21.0 182.6±22.4 <0.01 135.8±17.2 135.8±17.4 136.8±18.6 0.11

Body Mass Index (kg/m2) 25.3±2.4 25.2±2.3 25.6±2.6 <0.01 22.3±2.2 22.3±2.2 22.3±2.2 0.83 aFrom one-way analysis of variance

(2) Table 29 shows descriptive data on the lifestyle questionnaire variables. Some new

agents did not answer some questions and thus cell sizes do not necessarily add up to the total

number of men and women involved in the project. Although 42% of men and 39% of women

had smoked at least one cigarette in their lives (Question 10), only 17% of men and 14% of

women had smoked 100 cigarettes in their lives (Question 9). Because of the small number of

current smokers, Questions 11, 12, and 14 were combined into smokers and nonsmokers.

Smokers were defined as anyone smoking one or more cigarettes on one or more days in the last

30 days. Only about 3% of men and women were current smokers. Nineteen percent of men and

15% of women reported that they had quit smoking (Question 13).

(3) Because of the small number of smokeless tobacco users, Questions 15, 16, and 18

were combined into smokeless tobacco users and nonusers. Smokeless tobacco users were

defined as anyone using any amount of smokeless tobacco on one or more days in the last 30

days. There were almost twice as many smokeless tobacco users (n=24) as there were smokers

(n=13). About 6% of men and 1% of women were current smokeless tobacco users. Eight

percent of men and 2% of women reported that they had quit using smokeless tobacco (Question

17).

(4) When asked to self-rate their physical activity, 92% of men and 86% of women

reported that they were somewhat more active or much more active than their peers. About 96%

of men and 96% of women reported performing aerobic exercise at least 3 times per week in the

last 2 months; 80% of men and 91% of women performed aerobic exercise for at least 31

minutes. Weight training was performed at least 2 times per week by 76% of men and 77% of

women; 71% of men and 60% of women performed weight training for at least 31 minutes.

Fewer new agents played sports, with only 28% of men and 32% of woman reporting this at least

once a week in the last two months.

(5) When asked to self rate their endurance, sprint speed, strength, flexibility, push-up

performance, sit-up performance, and body fat, the proportion of men who rated themselves as

performing greater than average or much greater than average were 78%, 61%, 60%, 39%, 59%,


45

68%, and 25%, respectively. For women, these values were 72%, 51%, 56%, 43%, 55%, 61%,

and 16%, respectively.

(6) Over 60% of men and women reported prior injuries to the lower limbs while 42% of

men and 31% of women reported injuries to the upper limbs. Of the prior lower body injuries,

over 84% were severe enough to prevent normal activity; among prior upper limb injuries, 81%

of men and 72% of women had injuries severe enough to prevent normal activity. Most reported

that they had recovered from their prior injuries with only 5% of men and 6% of women

reporting that they had not returned to 100% activity after their lower limb injury; 6% of men

and 3% of women reported that they had not returned to 100% activity after their prior upper

limb injury.

(7) Foot, knee, and back pain limited the activity of 15%, 27% and 20% of men,

respectively; Foot, knee, and back pain limited the activity of 23%, 22% and 20% of women,

respectively.

(8) Only 2 women (2%) reported not having a menstrual cycle in a 6 month period. Over

half had used birth control pills in the last year, while few used other hormonal therapies.

Twelve percent of women had been pregnant in the past.

Table 29. Descriptive Data on New Agent Lifestyle Variables (from Questionnaire) Variable Category

Questiona Response Category

Men Women

N % N %

Tobacco Use

Q9. Smoked 100 Cigarettes in

Lifetime

No

Yes

352

74

82.6

17.4

90

15

85.7

14.3

Q10. Age Smoked First

Cigarette

Never Smoked

6-12 years

13-17 years

≥18 years

244

15

101

66

58.0

3.2

23.0

15.8

64

2

21

18

61.0

1.9

20.0

17.1

Q11. Days smoked in Last 30

Days

Nonsmoker

Smoked

413

13

96.9

3.1

102

3

97.1

2.9

Q12. Amount of Cigarettes per

Day in Last 30 Days

Nonsmoker

Smoked

413

13

96.9

3.1

102

3

97.1

2.9

Q13. If Quit Smoking, How

Long Ago

Never Smoked

Smoker

Quit 1-24 Months Ago

Quit ≥24 Months Ago

331

13

13

69

77.7

3.1

3.1

16.2

87

2

13

3

82.9

1.9

12.4

2.9

Q14. Time Smoking Nonsmoker

Smoker

413

13

96.9

3.1

102

3

97.1

2.9

Q15. Smokeless Tobacco Use

Last 30 Days

Users

Nonusers

402

24

94.4

5.6

104

1

99.0

1.0

Q16. Amount of Smokeless

Tobacco Last 30 Days

Users

Nonusers

402

24

94.4

5.6

104

1

99.0

1.0


46

Variable Category


Men Women

N % N %

Q17. If Quit Using Smokeless

Tobacco, How Long Ago

Never Used

Users

Quit 1-24 Months


369

24

16

17

86.6

5.6

3.8

4.0

102

1

1

1

97.1

1.0

1.0

1.0

Q18. Time Using Smokeless

Tobacco

Users

NonUsers

402

24

94.4

5.6

104

1

99.0

1.0

Physical Activity

Q19. Self Rating of

Physical Activity

Much Less Active

Somewhat Less Active

About the Same

Somewhat More Active

Much More Active

0

6

30

163

227

0.0

1.4

7.0

38.3

53.3

2

1

12

37

53

1.9

1.0

11.4

35.2

50.5

Q20. Frequency of Aerobic

Exercise in Last 2 Months

Never

< 1 time/week

1 time/week

2 times/week

3 times/week

4 times/week

5 times/week

6 times/week

≥ 7 times/week

0

0

2

17

124

123

102

48

10

0.0

0.0

0.5

4.0

29.1

28.9

23.9

11.3

2.3

0

0

0

4

25

27

31

16

2

0.0

0.0

0.0

3.8

23.8

25.7

29.5

15.2

1.9

Q21. Duration of Aerobic

Exercise per Session in Last 2

Months

None

1-15 minutes

16-30 minutes

31-45 minutes

46-60 minutes

61-75 minutes

76-90 minutes

>90 minutes

0

2

82

134

123

58

23

4

0.0

0.5

19.2

31.5

28.9

13.6

5.4

0.9

0

0

9

27

41

15

7

6

0.0

0.0

8.6

25.7

39.0

14.3

6.7

5.7

Q22. Frequency of Weight

Training in Last 2 Months

Never

< 1 time/week

1 time/week

2 times/week

3 times/week

4 times/week

5 times/week

6 times/week

≥ 7 times/week

40

32

32

77

127

71

36

11

0

9.4

7.5

7.5

18.1

29.8

16.7

8.5

2.6

0.0

10

7

7

29

34

11

5

2

0

9.5

6.7

6.7

27.6

32.4

10.5

4.8

1.9

0.0

Q23. Duration of Weight


None

1-15 minutes

16-30 minutes

31-45 minutes

46-60 minutes

61-75 minutes

76-90 minutes

>90 minutes

39

17

67

108

133

44

13

5

9.2

4.0

15.7

25.4

31.2

10.3

3.1

1.2

11

8

23

24

29

4

2

4

10.5

7.6

21.9

22.9

27.6

3.8

1.9

3.8

Q24. Frequency of Playing

Sports Last 2 Months

Never

< 1 time/week

1 time/week

2 times/week

202

105

69

32

47.4

24.6

16.2

7.5

50

21

20

8

47.6

20.0

19.0

7.6


47

Variable Category


Men Women

N % N %

3 times/week

4 times/week

5 times/week

6 times/week

≥ 7 times/week

11

5

2

0

0

2.6

1.2

0.5

0.0

0.0

4

2

0

0

0

3.8

1.9

0.0

0.0

0.0

Q25. Duration of Sports in Last

30 Days

None

1-15 minutes

16-30 minutes

31-45 minutes

46-60 minutes

61-75 minutes

76-90 minutes

>90 minutes

210

9

34

37

73

24

18

21

49.3

2.1

8.0

8.7

17.1

5.6

4.2

4.9

52

1

6

9

23

6

1

7

49.5

1.0

5.7

8.6

21.9

5.7

1.0

6.7

Fitness

Q26a. Self Rating of

Endurance

Far Less Than Average

Less Than Average

Average

Greater Than Average

Far Greater Than Average

0

16

79

264

67

0.0

3.8

18.5

62.0

15.7

0

5

24

66

9

0.0

4.8

23.1

63.5

8.7

Q26b. Self Rating of Sprint

Speed Far Less Than Average

Less Than Average

Average



3

15

148

209

51

0.7

3.5

34.7

49.1

12.0

0

7

45

48

5

0.0

6.7

42.9

45.7

4.8

Q26c. Self Rating of Strength Far Less Than Average

Less Than Average

Average



1

13

156

212

42

0.2

3.1

36.8

50.0

9.9

2

6

38

52

6

1.9

5.8

36.5

50.0

5.8

26d. Self Rating of Flexibility Far Less Than Average

Less Than Average

Average



4

70

187

136

28

0.9

16.4

43.9

31.9

6.6

2

14

44

36

9

1.9

13.3

41.9

34.3

8.6

26e. Self Rating of Push-Ups Far Less Than Average

Less Than Average

Average



0

21

152

213

40

0.0

4.9

35.7

50.0

9.4

3

9

35

49

9

2.9

8.6

33.3

46.7

8.6

26f. Self Rating of Sit-Ups Far Less Than Average

Less Than Average

Average



1

13

124

231

57

0.2

3.1

29.1

54.2

13.4

0

5

36

52

12

0.0

4.8

34.3

49.5

11.4

26g. Self Rating of Body Fat Far Less Than Average

Less Than Average

Average



46

126

148

77

29

10.8

29.6

34.7

18.1

6.8

3

31

54

12

5

2.9

29.5

51.4

11.4

4.8


48

Variable Category


Men Women

N % N %

Prior Injury

Q27. Injured Lower Limb No

Yes

167

259

39.2

60.8

40

65

38.1

61.9

Q28. Did Lower Limb Injury

Prevent You from Doing

Normal Physical Activity

No Injury

No

Yes

167

41

218

39.2

9.6

51.2

40

10

55

38.1

9.5

52.4

Q29. Returned to Normal

Physical Activity Since Lower

Limb Injury

No Injury

No

Yes

168

14

244

39.4

3.3

57.3

40

4

61

38.1

3.8

58.1

Q30. Injured Upper Limb No

Yes

248

178

58.2

41.8

73

32

69.5

30.5

Q31. Did Upper Limb Injury

Prevent You from Doing

Normal Physical Activity

No Injury

No

Yes

248

34

144

58.2

8.0

33.8

73

9

23

69.5

8.6

21.9


Physical Activity Since Upper

Limb Injury

No Injury

No

Yes

247

11

168

58.0

2.6

39.4

73

1

31

69.5

1.0

29.5

Pain Limiting

Activity

Q33. Have Foot Pain Limiting

Activity Sometime

No

Yes

363

63

85.2

14.8

81

24

77.1

22.9

Q34. Have Knee Pain Limiting

Activity Sometime

No

Yes

313

113

73.5

26.5

82

23

78.1

21.9

Q35. Have Back Pain Limiting

Activity Sometime

No

Yes

341

85

80.0

20.0

84

21

80.0

20.0

Menstrual History

Q36. Age of Menarche

8-11 Years

12-14 Years

≥15 Years

9

76

19

8.7

73.1

18.3

Q37. Menstrual Periods Last

Year

1-10 Periods

11-13 Periods

20

84

19.2

80.8

Q38. Gone ≥ 6 Months without

Menstrual Cycle

No

Yes

No Menstrual Period Yet

102

2

0

98.1

1.9

0.0

Q39. Used Birth Control in

Past 12 Months

No

Yes

47

57

45.2

54.8

Q40. Used Hormonal Therapy

in Past 12 Months

No

Yes

97

7

93.3

6.7

Q41. Ever Pregnancy No

Yes

90

12

88.2

11.8 aQ (with a number) refers to the question number on the lifestyle questionnaire

(9) Some items on the questionnaire required responses on a continuous numeric scale.

The average±SD responses for these questions are shown in Table 30. The two women who

reported that they no longer used smokeless tobacco reported quitting 1 and 180 months ago.


49

Table 30. New Agent Questionnaire Variables

Questiona

Men Women

N Mean SD n Mean SD

Q10. Age Smoked First Cigarette (years) 182 16.5 3.4 41 16.9 2.7

Q11. Days Smoked in Last 30 Days (# days) 13 5.9 9.3 3 4.3 4.9

Q12. Amount of Cigarettes per Day Over Last 30 Days (cigarettes/day) 13 2.4 2.5 3 5.7 8.1

Q13. If Quit Smoking, How Long Ago (months) 82 101 67 15 91 49

Q14. Time Smoking (years) 13 8.3 8.8 1 9.0

Q15. Smokeless Tobacco Use Last 30 Days (#days) 26 13.1 1 30

Q16. Amount of Smokeless Tobacco Last 30 Days (cans, plugs, pouches) 26 1.1 0.8 1 0.3

Q17. If Quit Using Smokeless Tobacco, How Long Ago (months) 33 60 61 2 91±127

Q18. Time Using Smokeless Tobacco (years) 26 8.8 4.9 1 5.0

Q22. Age of Menarche (years)

104 13.2 1.6

Q23. Menstrual Periods Last Year (n/year) 104 11.0 2.4

Q26. Time Since Last Pregnancy (months) 12 71.9 40.0 aQ (with a number) refers to the question number on the lifestyle questionnaire

(10) Table 31 shows demographic data from the medical examination (SF88) and New

Agent Trainee Profiles. Sixty-six percent of the men were married compared with only 34% of

the women (p<0.01); 43% of men had children, compared with only 13% of women (p<0.01).

With regard to advanced degrees, 40% of men had master’s or doctoral degrees, while 58% of

women had these degrees (p<0.01).


50

Table 31. New Agent Demographics from Medical Examination and New Agent Trainee Profile

Variable Level of Variable

Men Women

n % n %

Race

White

Hispanic

Asian

Black

American Indian

353

25

13

13

1

80.5

5.9

3.1

3.1

0.5

76

9

6

5

0

72.4

8.6

5.7

4.8

0.0

Married No

Yes

145

276

34.4

65.6

67

35

65.7

34.3

Children

None

1 Child

2 Children

3 Children

4 Children

5 Children

241

81

74

20

6

2

56.8

19.0

17.5

4.7

1.4

0.5

91

6

4

2

1

0

87.5

5.8

3.8

1.9

1.0

0.0

Entry Program

Accounting/Finance

Information Technology

Diversified

Engineering/Science

Intelligence

Language

Law

Law Enforcement/Military

Tactical Recruitment Program

48

32

130

33

30

26

28

51

34

11.7

7.8

31.6

8.0

7.3

6.3

6.8

12.4

8.2

11

4

34

12

11

8

16

3

0

11.1

4.0

34.3

12.1

11.1

8.1

16.2

3.0

0.0

Education

Bachelor of Science

Bachelor of Arts

Masters of Arts

Masters of Science

Masters of Business Administration

Masters of Public Administration

Juris Doctorate

Doctorate

149

105

32

63

32

6

30

7

35.1

24.8

7.5

14.9

7.5

1.4

7.1

1.7

21

23

18

20

7

0

15

0

20.2

22.1

17.3

19.2

6.7

0.0

14.4

0.0

Foreign Language No

Yes

291

133

68.6

31.4

56

48

53.8

46.2

Military Experience No

Yes

248

176

58.5

41.5

86

18

82.7

17.3

Law Enforcement Experience No

Yes

326

98

76.9

23.1

84

20

80.8

19.2

Dominate Hand

Right

Left

Ambidextrous

387

33

2

91.7

7.8

0.5

93

5

1

93.9

5.1

1.0

e. Descriptive Statistics on Physical Fitness Test Scores.

(1) Table 32 shows the initial PFT scores obtained within the first 2-3 days of entry into

the FBI Academy. Table 33 shows the initial and Week 7 PFT scores and the changes in scores

for individuals who took both tests before 3 August 2009. There were significant improvements


51

on all tests and the women improved more than the men on a relative (%) basis. For the men,

average±SD total points increased from 15.0±6.4 on the initial test to 17.2±4.6 (p<0.01) on the

Week 7 test, a 14.7% improvement. For the women, average±SD total points increased from

12.0±5.1 on the initial test to 17.3±4.8 (p<0.01) on the Week 7 test, a 44.2% improvement.

Table 32. New Agent Initial Physical Fitness Test Scores Men Women

N Mean±SD Minimum/

Maximum

N Mean±SD Minimum/

Maximum

Push-Ups (n) 426 37±9 0/71 105 17±8 0/39

Sit-Ups (n) 426 44±5 28/59 105 42±6 26/51

300-Meter Run (sec) 426 45.9±2.4 40/55 105 56.1±3.0 46/62

1.5-Mile Run (min) 425 11.1±1.0 8.1/15.0 105 12.5±0.9 10.1/14.9

Pull-Ups(n) 424 8.1±4.4 0/22 105 0.7±1.8 0/12

Total Score (points) 426 14.9±5.7 1/37 105 12.4±4.6 2/27

Table 33. Comparison of New Agent Initial and Week 7 Physical Fitness Tests (tests taken

before 3 August 2009) Gender Week Push-Ups

(repetitions)

Sit-Up

(repetitions)

300-Meter Run

(sec) 1.5-Mile Run

(min)

Pull-Ups

(repetitions)

N M±SD N M±SD N M±SD N M±SD N M±SD

Men

Week 1 262 36±9 262 44±5 262 46.1±2.6 258 11.2±1.0 246 7.9±4.5

Week 7 262 39±8 262 49±4 262 45.7±2.5 258 10.8±0.8 246 8.6±4.6

ΔWeek 1 to 7 3 5 0.4 0.4 0.7

ΔWeek 1 to 7 (%)a 7.4 11.7 0.9 3.4 8.7

p-valueb <0.01 <0.01 <0.01 <0.01 <0.01

Women

Week 1 72 16±8 72 41±6 72 56.3±3.1 72 12.5±1.0 68 0.9±2.0

Week 7 72 21±6 72 47±4 72 54.8±3.5 72 12.0±0.9 68 1.2±2.2

ΔWeek 1 to 7 5 6 1.5 0.5 0.3

Δ Week 1 to 7 (%)a 28.8 14.3 2.6 3.8 45.9

p-valueb <0.01 <0.01 <0.01 <0.01 <0.01 aCalculated as |(Week 7-Week 1/Week 1) X 100%| bPaired t-test

(2) Table 34 shows the initial and week 9 PFT scores and the changes in scores for

individuals who took both PFTs after 3 August 2009. There were significant improvements on

all tests and the women improved more than the men on both a relative (%) and absolute basis.

For the men, average±SD total points increased from 15.1±4.3 on the initial test to 19.8±4.2

(p<0.01) on the Week 9 test, a 31.1% improvement. For the women, average±SD total points

increased from 13.4±3.5 on the initial test to 19.5±2.6 (p<0.01) on the Week 9 test, a 45.5%

improvement.


52

Table 34. Comparison of New Agent Initial and Week 9 Physical Fitness Tests (tests taken after

3 August 2009)

aCalculated as |(Week 9-Week 1/Week 1) X 100%| bPaired t-test

(3) Table 35 shows the initial, Week 7, and Week 14 PFT scores and the changes in

scores. The only new agents required to take the Week 14 test were those who failed the initial

and Week 7 tests, so the sample sizes are small. As might be expected, initial scores were lower

than for the larger sample (Table 32). There were significant improvements on all tests over the

14 week period and the women improved more than the men on a relative (%) and an absolute

basis. For the men, average±SD total points were 11.5±6.3, 10.8±3.1, and 13.9±2.7 on the

initial, Week 7, and Week 14 tests, respectively (p<0.01), a 20.9% improvement overall. For the

women, average±SD total points were 7.3±2.5, 10.2±1.9, and 14.9±3.2 on the initial, Week 7,

and Week 14 tests, respectively (p<0.01), a 104.1% improvement overall.

Table 35. Comparison of New Agent Initial, Week 7, and Week 14 Physical Fitness Tests Gender Week Push-Ups

(repetitions)

Sit-Up

(repetitions)

300-Meter Run

(sec) 1.5-Mile Run

(min)

Pull-Ups

(repetitions)


Men Week 1 33 29±8 33 41±4 33 47.8±2.5 30 11.6±0.6 29 4.3±3.0

Week 7 33 28±8 33 46±4 33 47.6±2.3 30 11.3±0.6 29 5.4±2.7

Week 14 33 33±7 33 48±2 33 47.1±2.6 30 11.1±0.6 29 5.4±3.5

▲Week 1 to 14 4 7 0.9 0.5 1.1

▲Week 1 to 14 (%)a 15.1 16.3 1.7 4.1 24.0

p-valueb <0.01 <0.01 <0.01 <0.01 <0.01

Women

Week 1 9 11±7 9 41±5 9 58.8±2.4 9 13.5±1.1 9 0.1±0.3

Week 7 9 13±4 9 46±3 9 58.2±2.2 9 13.3±1.0 9 0.2±0.4

Week 14 9 20±7 9 51±3 9 55.4±4.7 9 12.9±0.9 9 1.2±2.9

▲Week 1 to 14 9 10 3.4 0.6 1.1

▲Week 1 to 14 (%)a 81.9 23.2 5.7 4.3 1100.0

p-valueb <0.01 <0.01 <0.01 <0.01 <0.01 aCalculated as |(Week 14-Week 1/Week 1) X 100%| bOne-way repeated measures analysis of variance

Gender Week Push-Ups

(repetitions)

Sit-Up

(repetitions)

300-Meter Run

(sec) 1.5-Mile Run

(min)

Pull-Ups

(repetitions)


Men

Week 1 146 38±9 146 45±5 146 45.6±2.2 146 10.9±0.9 146 8.6±4.3

Week 9 146 41±7 146 50±5 146 44.8±2.0 146 10.5±0.8 146 9.3±4.2

ΔWeek 1 to 9 3 5 0.8 0.4 0.7

ΔWeek 1 to 9 (%)a 8.4 10.7 1.8 3.7 7.8

p-valueb <0.01 <0.01 <0.01 <0.01 <0.01

Women

Week 1 26 17±6 26 43±6 26 55.7±2.4 26 12.4±0.8 26 0.3±0.8

Week 7 26 22±6 26 48±5 26 53.8±2.2 26 11.8±0.7 26 0.6±1.3

ΔWeek 1 to 9 5 5 1.9 0.6 0.3

ΔWeek 1 to 9 (%)a 28.7 12.5 3.3 4.1 100.0

p-valueb <0.01 <0.01 <0.01 <0.01 <0.01


53

(4) Table 36 shows the initial, Week 9 and Week 18 PFT scores and the changes in scores.

The only new agents required to take the Week 18 test were those who failed the initial and

Week 9 tests, so the sample sizes are small. As might be expected, initial scores were lower than

for the larger sample (Table 32). For the 7 men, there were significant improvements on the

push-ups and sit-ups. While men improved somewhat on Week 9 on the 300-meter and 1.5-mile

runs, their 18 week performance was similar to their lower initial performance. In fact, the

average point score declined slightly on the 18 week test compared with the 9 week test. For the

men, average±SD total points were 11.3±4.4, 15.3±4.4, and 14.9±2.0 on the initial, Week 9, and

Week 18 tests, respectively (p<0.01), a 31.9% improvement overall (initial to Week 18). Only 1

woman took all three tests. She showed progressive improvements on push-ups and sit-ups but

her performance on Week 18 was lower than her performance on Week 9 for the 300-meter and

1.5-mile runs. Her total points were 11, 19, and 17 on the initial, Week 9, and Week 18 tests,

respectively, a 54.5% improvement overall (initial to Week 18).

Table 36. Comparison of New Agent Initial, Week 9, and Week 18 Physical Fitness Tests Gender Week Push-Ups

(repetitions)

Sit-Up

(repetitions)

300-Meter Run

(sec) 1.5-Mile Run

(min)

Pull-Ups

(repetitions)


Men Week 1 7 1±2 7 42±5 7 46.7±3.0 7 10.7±1.2 7 5.6±5.4

Week 9 7 28±2 7 47±3 7 45.7±2.7 7 10.4±0.8 7 7.1±3.3

Week 18 7 32±3 7 47±3 7 46.3±2.2 7 10.7±0.9 7 6.9±2.7

ΔWeek 1 to 18 31 5 0.4 0 1.3

ΔWeek 1 to 18 (%)a 5233.33 12.2 0.9 0.0 23.2

p-valueb <0.01 <0.01 0.25 0.43 0.32 Women Week 1 1 0 1 44 1 58.0 1 12.3 1 0

Week 9 1 5 1 48 1 53.8 1 11.1 1 0

Week 18 1 12 1 53 1 54.1 1 12.1 1 0

ΔWeek 1 to 18 12 9 3.9 0.2 0

ΔWeek 1 to 18 (%)a --- 20.5 6.7 1.6 0

p-valueb --- --- --- --- --- aCalculated as |(Week 18-Week 1/Week 1) X 100%| bOne-way repeated measures analysis of variance

f. Univariate Associations of Injury with Other Variables.

(1) When hazard ratios were considered, women tended to have a slightly higher risk for

any injury compared with the men (HR (women/men)=1.34, 95%CI=0.95-1.87, p=0.09). Table

37 shows the univariate associations between any injury and age, physical characteristics, and

physical fitness among male new agents. Higher injury incidence was associated with older age,

slower 300-meter sprint time, slower 1.5-mile run time, and fewer total PFT points. Those with

body mass indices in the third quartile (between about 25 and 27 kg/m2) tended to have higher

injury risk than those with lower BMI but risk was lower in the highest BMI quartile. Note that

injury risk was elevated in the lower performing quartiles for all the physical fitness measures,

regardless of statistical significance.


54

Table 37. Univariate Associations between Injury Risk and Age, Physical Characteristics, and

Physical Fitness among Male New Agents Variable Level of Variable N Injured

(%)

Hazard Ratios (95%CI)

from Cox Regressions

p-value (from Wald

statistic)

Age 24.4-29.9 Years

30.0-38.6 Years

188

238

26.6

41.6

1.00

1.83 (1.30-2.57)

Referent

<0.01

Height 57-69 inches

70 inches

71 inches

72-81 inches

123

73

65

165

35.0

30.1

38.5

35.8

1.02 (0.69-1.51)

0.79 (0.48-1.28)

1.10 (0.69-1.75)

1.00

0.93

0.34

0.70

Referent

Weight 114-167 pounds

168-180 pounds

181-195 pounds

196-250 pounds

109

127

99

91

33.9

33.1

32.3

41.8

1.00

0.98 (0.61-1.57)

0.98 (0.61-1.57)

1.24 (0.79-1.95)

Referent

0.91

0.92

0.35

Body Mass

Index

16.51-23.74 kg/m2

23.75-25.11 kg/m2

25.12-26.63 kg/m2

26.64-38.74 kg/m2

108

110

103

105

34.3

25.5

48.5

32.4

1.00

0.74 (0.46-1.22)

1.54 (1.00-2.36)

0.95 (0.60-1.52)

Referent

0.24

0.05

0.84

Pull-Ups 0-4 repetitions

5-8 repetitions

9-11 repetitions

12-22 repetitions

94

138

92

100

41.5

33.3

27.2

38.0

1.12 (0.72-1.75)

0.85 (0.55-1.31)

0.64 (0.39-1.06)

1.00

0.62

0.46

0.08

Referent

Push-Ups 1-31 repetitions

32-36 repetitions

37-42 repetitions

43-71 repetitions

104

112

106

104

37.5

40.2

30.2

31.7

1.20 (0.76-1.91)

1.38 (0.88-2.16)

0.97 (0.60-1.58)

1.00

0.44

0.16

0.91

Referent

Sit-Ups 28-40 repetition

41-44 repetitions

45-47 repetitions

48-59 repetitions

97

132

101

96

42.7

34.0

29.5

35.6

1.32 (0.83-2.09)

1.05 (0.65-1.68)

0.84 (0.53-1.34)

1.00

0.23

0.84

0.46

Referent

300-Meter

Sprint

40-44 seconds

45-46 seconds

47-48 seconds

49-55 seconds

123

132

108

63

28.5

34.1

39.8

41.3

1.00

1.23 (0.79-1.91)

1.48 (0.95-2.32)

1.71 (1.03-2.84)

Referent

0.36

0.08

0.04

1.5-Mile Run 8.18-10.35 minutes

10.36-11.10 minutes

11.11-11.64 minutes

11.65-15.02 minutes

108

107

104

106

25.9

30.8

37.5

45.3

1.00

1.24 (0.75-2.05)

1.60 (0.99-2.61)

2.06 (1.30-3.29)

Referent

0.41

0.06

<0.01

Physical

Fitness Test

Score

1-11 points

12-14 points

15-18 points

19-37 points

114

107

108

97

43.0

30.8

36.1

28.9

1.73 (1.09-2.75)

1.15 (0.70-1.91)

1.35 (0.82-2.17)

1.00

0.02

0.58

0.24

Referent

(2) Table 38 shows the univariate associations between any injury and age, physical

characteristics, and physical fitness among female new agents. Because 74% of the women

could not perform a single pull-up, this variable was separated into those who could and who

could not perform at least one pull-up. Higher injury incidence was associated with slower 300-

meter sprint time, slower 1.5-mile run time, and fewer total PFT points. There was little


55

association between injury risk and the physical characteristics. Similar to the men, injury risk

was elevated in the lower performance quartiles for all the physical fitness measures, regardless

of statistical significance.

Table 38. Univariate Associations between Injury Risk and Age, Physical Characteristics, and

Physical Fitness among Female New Agents Variable Level of Variable N Injured

(%)

Hazard Ratios

(95%CI)

from Cox Regressions

p-value (from

Wald statistic)

Age 24.1-29.9 years

30.0-37.0 years

60

45

36.7

48.9

1.00

1.52 (0.84-2.75)

Referent

0.16

Height 58-64 inches

65-66 inches

67-71 inches

39

31

35

46.2

45.2

34.3

1.49 (0.72-3.10)

1.45 (0.67-3.14)

1.00

0.28

0.35

Referent

Weight 105-125 pounds

126-140 pounds

141-200 pounds

35

35

35

42.9

45.7

37.1

1.00

1.15 (0.57-2.33)

0.91 (0.43-1.91)

Referent

0.70

0.80

Body Mass

Index

18.25-21.26 kg/m2

21.27-23.30 kg/m2

23.31-29.54 kg/m2

37

34

34

43.2

44.1

38.2

1.00

1.13 (0.56-2.29)

0.93 (0.45-1.94)

Referent

0.73

0.85

Pull-Ups 0 repetitions

1-12 repetitions

78

27

43.6

37.0

1.17 (0.58-2.37)

1.00

0.66

Referent

Push-Ups 0-13 repetitions

14-20 repetitions

21-39 repetitions

36

35

34

50.0

37.1

38.2

1.38 (0.67-2.81)

0.95 (0.44-2.04)

1.00

0.38

0.89

Referent

Sit-Ups 26-40 repetition

41-44 repetitions

45-51 repetitions

38

34

33

42.1

47.1

36.4

1.28 (0.61-2.71)

1.44 (0.68-3.05)

1.00

0.52

0.34

Referent

300-Meter

Sprint

46-55 seconds

56-58 seconds

59-62 seconds

42

41

22

35.7

39.0

59.1

1.00

1.17 (0.58-2.37)

2.23 (1.06-4.70)

Referent

0.66

0.04


12.07-12.95 minutes

12.96-14.92 minutes

35

35

35

40.0

37.1

62.9

1.00

0.90 (0.42-1.92)

1.95 (1.00-3.80)

Referent

0.80

0.05

Physical

Fitness Test

Score

2-10 points

11-14 points

15-27 points

38

32

35

47.4

43.8

34.3

2.04 (1.00-4.14)

1.77 (0.84-3.71)

1.00

0.05

0.13

Referent

(3) Table 39 shows the univariate associations between any injury and tobacco use,

physical activity, self-reported fitness, prior injury, and pain limiting activity in the male new

agents. Smoking in the past 30 days was not associated with injury risk. On the other hand,

those who had smoked 100 cigarettes in their lifetime, had smoked their first cigarette at an older

age, or had quit smoking more than 24 months ago were at lower injury risk. Smokeless tobacco

use in the past 30 days was not associated with injury risk.

(4) Higher injury risk was associated with a lower self rating of physical activity and a

lower frequency of aerobic exercise in the past 2 months. Although not statistically significant,

higher injury risk was associated with a lower frequency of weight training. Interestingly, longer


56

duration of aerobic exercise was associated with higher injury risk and a similar (though not

statistically significant) trend was seen for weight training duration.

(5) Higher injury risk was associated with a lower self-rating of endurance. Those rating

themselves as having average sit-up performance tended to have lower injury risk than those who

rated themselves as having greater than average performance. A similar trend was seen for push-

up performance.

(6) Men who reported a prior upper or lower limb injury tended to be at higher injury risk.

If the men reported that injury to either limb prevented physical activity for at least 1 week, the

risk of injury during new agent training was also elevated. If the men had not returned to normal

activity after either limb injury, injury risk during new agent training was further elevated.

(7) Men who reported having foot or knee pain that limited activity were at elevated

injury risk. Back pain limiting activity also elevated injury risk but less so than foot or knee

pain.

Table 39. Univariate Associations between Injury Risk and Questionnaire Variables among

Male New Agents Variable

Category

Variable Level of Variable N Injured

(%)

Hazard Ratios

(95%CI)

from Cox

Regressions

p-value

(from Wald

statistic)

Tobacco

Use

Q9. Smoked 100 Cigarettes

in Lifetime

No

Yes

352

74

36.9

25.7

1.00

0.63 (0.40-1.03)

Referent

0.07


Cigarette

Never Smoked

6-17 years

≥18 years

244

116

66

41.4

26.7

25.8

1.00

0.56 (0.37-0.84)

0.56 (0.34-0.94)

Referent

<0.01

0.03

Q11. Days smoked in Last

30 Days

Nonsmoker

Smoked

413

13

34.9

38.5

1.00

1.04 (0.42-2.56)

Referent

0.92

Q12. Cigarettes per Day in

Last 30 Days

Nonsmoker

Smoked

413

13

34.9

38.5

1.00

1.04 (0.42-2.56)

Referent

0.92


Long Ago

Never Smoked

Smoker



331

13

13

69

36.9

38.5

38.5

24.6

1.00

0.97 (0.40-2.38)

0.92 (0.38-2.25)

0.62 (0.37-1.03)

Referent

0.95

0.86

0.06


Smoker

413

13

34.9

38.5

1.00

1.04 (0.42-2.56)

Referent

0.92

Q15. Smokeless Tobacco

Use Last 30 Days

Nonusers

Users

402

24

35.1

33.3

1.00

0.92 (0.45-1.88)

Referent

0.82



Nonusers

Users

402

24

35.1

33.3

1.00

0.92 (0.45-1.88)

Referent

0.82


57

Variable

Category


(%)

Hazard Ratios

(95%CI)

from Cox

Regressions

p-value

(from Wald

statistic)

Q17. If Quit Using

Smokeless Tobacco, How

Long Ago

Never Used

Users

Quit 1-24 Months


369

24

16

17

35.2

33.3

31.3

35.3

1.00

0.92 (0.45-1.87)

0.80 (0.33-1.96)

1.05 (0.46-2.37)

Referent

0.81

0.63

0.92

Q18. Time Using

Smokeless Tobacco

Users

NonUsers

402

24

35.1

33.3

1.00

0.92 (0.45-1.88)

Referent

0.82

Physical

Activity

Q19. Self Rating of

Physical Activity

Less Active

About the Same

More Active

6

30

390

83.3

26.7

34.9

4.60 (1.88-11.26)

0.75 (0.37-1.52)

1.00

<0.01

0.42

Referent



≤ 1 time/week

2-4 times/week

≥5 times/week

2

264

160

100.0

31.4

40.0

5.96 (1.44-24.69)

0.75 (0.54-1.03)

1.00

0.01

0.08

Referent


Exercise Last 2 Months

0-30 minutes

31-60 minutes

≥61 minutes

84

257

85

34.5

32.3

43.5

0.73 (0.45-1.19)

0.70 (0.48-1.03)

1.00

0.02

0.07

Referent



≤ 1 time/week

2-4 times/week

≥5 times/week

104

275

47

40.4

33.5

31.9

1.40 (0.78-2.52)

1.06 (0.61-1.83)

1.00

0.26

0.84

Referent



0-30 minutes

31-60 minutes

≥61 minutes

123

241

62

33.3

34.0

41.9

0.80 (0.49-1.31)

0.78 (0.50-1.22)

1.00

0.38

0.28

Referent



≤ 1 time/week

2-4 times/week

≥5 times/week

376

48

2

35.4

31.3

50.0

0.61 (0.09-4.36)

0.50 (0.07-3.82)

1.00

0.62

0.51

Referent

Q25. Duration of Sports in

Last 30 Days

0-30 minutes

31-60 minutes

≥61 minutes

253

110

63

36.8

30.0

36.5

1.01 (0.64-1.59)

0.79 (0.46-1.35)

1.00

0.97

0.39

Referent

Physical

Fitness


Endurance

Less Than Average

Average


16

79

331

68.8

36.7

32.9

1.70 (1.45-5.01)

1.15 (0.76-1.73)

1.00

<0.01

0.51

Referent


Speed Less Than Average

Average


18

148

260

38.9

35.1

34.6

1.23 (0.57-2.65)

0.99 (0.71-1.40)

1.00

0.60

0.97

Referent

Q26c. Self Rating of

Strength Less Than Average

Average


14

156

254

35.7

34.6

35.0

1.07 (0.43-2.63)

1.01 (0.72-1.41)

1.00

0.89

0.98

Referent

Q26d. Self Rating of

Flexibility Less Than Average

Average


74

187

164

36.5

31.6

37.8

0.92 (0.59-1.45)

0.80 (0.56-1.14)

1.00

0.72

0.22

Referent

Q26e. Self Rating of Push-

Up Performance Less Than Average

Average


21

152

253

52.4

28.9

37.2

1.43 (0.77-2.57)

0.75 (0.52-1.07)

1.00

0.26

0.11

Referent

Q26f. Self Rating of Sit-Up

Performance Less Than Average

Average


14

124

288

35.7

29.0

37.5

0.98 (0.40-2.41)

0.70 (0.48-1.02)

1.00

0.97

0.07

Referent

Q26g. Self Rating of Body

Fat

Less Than Average

Average


172

148

106

37.2

35.8

30.2

1.28 (0.83-1.95)

1.23 (0.79-1.91)

1.00

0.26

0.36

Referent


58

Variable

Category


(%)

Hazard Ratios

(95%CI)

from Cox

Regressions

p-value

(from Wald

statistic)

Prior

Injury

Q27. Prior Lower Limb

Injury

No

Yes

167

259

29.3

38.6

1.00

1.45 (1.03-2.04)

Referent

0.03

Q28. Lower Limb Injury

Prevented Normal Physical

Activity for ≥1 week

No Injury

No

Yes

167

41

218

29.3

34.1

39.4

1.00

1.17 (0.65-2.12)

1.51 (1.06-2.14)

Referent

0.60

0.02


Physical Activity Since

Lower Limb Injury

No Injury

No

Yes

168

14

244

29.8

64.3

36.9

1.00

2.97 (1.46-6.05)

1.35 (0./95-1.91)

Referent

<0.01

0.09


Yes

248

178

31.0

40.4

1.00

1.38 (1.00-1.88)

Referent

0.05

Q31. Upper Limb Injury


Activity for ≥1 Week

No Injury

No

Yes

248

34

144

31.0

35.3

41.7

1.00

1.13 (0.62-2.08)

1.43 (1.02-2.00)

Referent

0.70

0.04



Upper Limb Injury

No Injury

No

Yes

247

11

168

30.8

72.7

38.7

1.00

2.93 (1.41-6.08)

1.31 (0.94-1.83)

Referent

<0.01

0.11

Pain

Limiting

Activity

Q33. Have Foot Pain

Limiting Activity at Times

No

Yes

363

63

32.5

49.2

1.00

1.64 (1.10-2.44)

Referent

0.01

Q34. Have Knee Pain


No

Yes

313

113

31.3

45.1

1.00

1.67 (1.19-2.34)

Referent

<0.01

Q35. Have Back Pain


No

Yes

341

85

32.8

43.5

1.00

1.33 (0.92-1.93)

Referent

0.13

(8) Table 40 shows the univariate associations between injuries and tobacco use, physical

activity, self-assessed fitness, prior injury, pain limiting activity, and menstrual history in the

female new agents. Few of the questionnaire variables were significantly associated with injury

among the women, presumably because of the small sample size. However, some of the trends

followed those of the men. Although only three female new agents reported that they were less

physically active than their peers, injury risk was elevated in these less active women, compared

with the more active. Longer exercise durations tended to be associated with higher injury risk,

especially for those performing weight training for longer periods. Although only five female

new agents self-rated their endurance as less than average, injury risk tended to be elevated in

this group compared with those who rated their endurance as greater than average. Foot, knee,

or back pain that limited activity tended to be associated with elevated injury risk, and this was

statistically significant for back pain. In contrast to the men, prior upper or lower limb injury

had little association with injury risk in new agent training.


59

Table 40. Univariate Associations between Injury Risk and Questionnaire Variables among

Female New Agents Variable

Category


(%)

Hazard Ratios

(95%CI)

from Cox

Regressions

p-value

(from Wald

statistic)

Tobacco Use


in Lifetime

No

Yes

90

15

41.1

46.7

1.00

1.17 (0.52-2.61)

Referent

0.71


Cigarette

Never Smoked

6-17 years

≥18 years

64

23

18

35.9

52.2

50.0

1.00

1.65 (0.82-3.32)

1.39 (0.65-3.01)

Referent

0.16

0.40

Q11. Days smoked in Last

30 Days

Nonsmoker

Smoked

102

3

42.2

33.3

1.00

0.69 (0.09-4.97)

Referent

0.71

Q12. Cigarettes per Day in

Last 30 Days

Nonsmoker

Smoked

102

3

42.2

33.3

1.00

0.69 (0.09-4.97)

Referent

0.71


Long Ago

Never Smoked

Smoker



87

3

2

13

42.5

33.3

0.0

46.2

1.00

0.68 (0.09-4.94)

-----

1.12 (0.47-2.66)

Referent

0.70

-----

0.79


Smoker

102

3

42.2

33.3

1.00

0.69 (0.09-4.97)

Referent

0.71

Q15. Smokeless Tobacco

Use Last 30 Days

Nonusers

Users

104

1

42.3

0.0

1.00

-----

Referent

-----



Nonusers

Users

104

1

42.3

0.0

1.00

-----

Referent

-----

Q17. If Quit Using

Smokeless Tobacco, How

Long Ago

Never Used

Users

Quit 1-24 Months


102

1

1

1

42.7

0.0

0.0

0.0

1.00

-----

-----

-----

Referent

-----

-----

-----

Q18. Time Using

Smokeless Tobacco

Users

NonUsers

104

1

42.3

0.0

1.00

-----

Referent

-----

Physical

Activity

Q19. Self Rating of

Physical Activity

Less Active

About the Same

More Active

3

12

90

66.7

33.3

42.2

2.18 (0.53-9.06)

0.69 (0.25-1.94)

1.00

0.28

0.48

Referent



≤ 1 time/week

2-4 times/week

≥5 times/week

0

56

49

---

44.6

38.8

-----

1.14 (0.63-2.07)

1.00

-----

0.67

Referent


Exercise Last 2 Months

0-30 minutes

31-60 minutes

≥61 minutes

9

68

28

44.4

38.2

50.0

0.89 (0.29-2.70)

0.77 (0.40-1.45)

1.00

0.83

0.40

Referent



≤ 1 time/week

2-4 times/week

≥5 times/week

24

74

7

41.7

41.9

42.9

0.90 (0.25-3.28)

0.88 (0.27-2.89)

1.00

0.88

0.84

Referent



0-30 minutes

31-60 minutes

≥61 minutes

42

53

10

40.5

37.7

70.0

0.46 (0.19-1.10)

0.38 (0.16-0.90)

1.00

0.08

0.03

Referent



≤ 1 time/week

2-4 times/week

≥5 times/week

91

14

0

40.7

50.0

---

0.76 (0.34-1.71)

1.00

-----

0.51

Referent

-----

Q25. Duration of Sports in

Last 30 Days

0-30 minutes

31-60 minutes

≥61 minutes

59

32

14

42.4

37.5

50.0

0.85 (0.37-1.97)

0.71 (0.28-1.80)

1.00

0.71

0.48

Referent


60

Variable

Category


(%)

Hazard Ratios

(95%CI)

from Cox

Regressions

p-value

(from Wald

statistic)

Fitness


Endurance

Less Than Average

Average


5

24

75

60.0

41.7

40.0

1.87 (0.57-6.13)

1.12 (0.55-2.30)

1.00

0.30

0.75

Referent


Speed Less Than Average

Average


7

45

53

57.1

37.8

43.4

1.96 (0.68-5.67)

0.81 (0.44-1.52)

1.00

0.22

0.52

Referent

Q26c. Self Rating of

Strength Less Than Average

Average


8

38

58

50.0

44.7

37.9

1.36 (0.47-3.96)

1.18 (0.63-2.23)

1.00

0.57

0.61

Referent

Q26d. Self Rating of

Flexibility Less Than Average

Average


16

44

45

31.3

45.5

42.2

0.63 (0.24-1.69)

1.16 (0.62-2.18)

1.00

0.36

0.64

Referent

Q26e. Self Rating of Push-

Up Performance Less Than Average

Average


12

35

58

41.7

40.0

43.1

0.94 (0.36-2.45)

0.84 (0.43-1.61)

1.00

0.90

0.59

Referent

Q26f. Self Rating of Sit-Up

Performance Less Than Average

Average


5

36

64

40.0

41.7

42.2

0.98 (0.23-4.10)

0.95 (0.50-1.78)

1.00

0.97

0.95

Referent

Q26g. Self Rating of Body

Fat

Less Than Average

Average


34

54

17

32.4

46.3

47.1

1.00

1.69 (0.83-3.44)

1.42 (0.57-3.52)

Referent

0.15

0.45

Prior Injury

Q27. Injured Lower Limb

No

Yes

40

65

42.5

41.5

1.00

1.07 (0.59-1.97)

Referent

0.82

Q28. Lower Limb Injury


Activity for ≥ 1 Week

No Injury

No

Yes

40

10

55

42.5

30.0

43.6

1.00

0.73 (0.22-2.50)

1.14 (0.61-2.12)

Referent

0.62

0.68



Lower Limb Injury

No Injury

No

Yes

40

4

61

42.5

50.0

41.0

1.00

1.29 (0.30-5.61)

1.06 (0.57-1.96)

Referent

0.73

0.86


Yes

73

32

41.1

43.8

1.00

1.04 (0.55-1.97)

Referent

0.90

Q31. Upper Limb Injury


Activity for ≥1 Week

No Injury

No

Yes

73

9

23

41.1

33.3

47.8

1.00

0.88 (0.27-2.88)

1.10 (0.55-2.20)

Referent

0.83

0.79



Upper Limb Injury

No Injury

No

Yes

73

1

31

41.1

0.0

45.2

1.09 (0.58-2.05)

-----

1.00

0.97

-----

Referent

Pain Limiting

Activity

Q33. Have Foot Pain


No

Yes

81

24

39.5

50.0

1.00

1.46 (0.75-2.84)

Referent

0.27

Q34. Have Knee Pain


No

Yes

82

23

41.5

43.5

1.00

1.24 (0.61-2.51)

Referent

0.55

Q35. Have Back Pain


No

Yes

84

21

35.7

66.7

1.00

2.33 (1.23-4.40)

Referent

<0.01


61

Variable

Category


(%)

Hazard Ratios

(95%CI)

from Cox

Regressions

p-value

(from Wald

statistic)

Menstrual

History

Q36. Age of Menarche

8-11 Years

12-14 Years

≥15 Years

9

76

19

22.2

46.1

31.6

0.43 (0.10-1.77)

1.00

0.61 (0.26-1.45)

0.24

Referent

0.26

Q37. Menstrual Periods

Last Year

1-10

11-13

20

84

40.0

41.7

0.85 (0.40-1.84)

1.00

0.69

Referent

Q38. Gone ≥ 6 Months

without Menstrual Cycle

No

Yes

102

2

40.2

100.0

1.00

2.84 (0.69-11.77)

Referent

0.15

Q39. Used Birth Control in

Past 12 Months

No

Yes

47

57

48.9

35.1

1.52 (0.84-2.77)

1.00

0.17

Referent

Q40. Used Hormonal

Therapy in Past 12 Months

No

Yes

97

7

41.2

42.9

0.88 (0.27-2.85)

1.00

0.83

Referent

Q41. Ever Pregnancy No

Yes

90

12

40.0

41.7

1.00

1.02 (0.40-2.61)

Referent

0.96

(9) Table 41 shows the univariate associations between demographic variables and injury

risk in new agent men. Injury risk was associated with having children but none of the other

demographic variables.


62

Table 41. Univariate Associations between Injury Risk and Demographic Variables among Male

New Agents Variable Level of Variable N Injured

(%)

Hazard Ratios

(95%CI)

from Cox

Regressions

p-value

(from Wald

statistic)

Race

White

Hispanic

Asian

Black

American Indian

343

25

13

13

1

34.4

36.0

46.2

30.8

0.0

1.00

1.03 (0.52-2.02)

1.34 (0.59-3.05)

0.81 (0.33-2.40)

-----

Referent

0.94

0.48

0.81

-----

Married No

Yes

145

276

31.0

36.2

1.00

1.22 (0.86-1.74)

Referent

0.26

Children None

1 or More

241

184

31.1

39.3

1.00

1.40 (1.01-1.93)

Referent

0.04

Entry Program

Accounting/Finance


Diversified

Engineering/Science

Intelligence

Language

Law


Tactical

TRP

48

32

130

33

30

26

28

51

15

19

35.4

31.3

36.9

30.3

36.7

38.5

35.7

23.5

40.0

36.8

1.00

0.89 (0.41-1.94)

1.02 (0.59-1.77)

0.82 (0.37-1.80)

1.01 (0.47-2.16)

1.04 (0.48-2.27)

0.95 (0.44-2.08)

0.57 (0.27-1.20)

1.16 (0.46-2.94)

1.02 (0.42-2.46)

Referent

0.77

0.95

0.63

0.97

0.92

0.91

0.14

0.75

0.97

Educational Level Bachelor Degree

Master’s or Doctoral Degree

254

170

31.5

39.4

1.00

1.09 (0.79-1.51)

Referent

0.70

Foreign Language No

Yes

291

133

32.2

39.8

1.00

1.29 (0.92-1.80)

Referent

0.14


Yes

248

176

35.5

33.5

1.00

0.92 (0.66-1.27)

Referent

0.60

Law Enforcement Experience No

Yes

326

98

35.3

32.7

1.00

0.84 (0.57-1.25)

Referent

0.39

Dominate Hand

Right

Left

Ambidextrous

387

33

2

43.1

39.4

50.0

1.00

1.23 (0.69-2.17)

1.58 (0.22-11.32)

Referent

0.48

0.65

(10) Table 42 shows the univariate associations between demographic variables and injury

risk in female new agents. Higher injury risk was associated with Hispanic race, lack of military

experience, and being left-handed.


63

Table 42. Univariate Associations between Injury Risk and Demographic Variables among

Female New Agents Variable Level of Variable N Injured

(%)

Hazard Ratios

(95%CI)

from Cox

Regressions

p-value (from Wald

statistic)

Race

White

Hispanic

Asian

Black

76

9

6

5

34.2

88.9

50.0

20.0

1.00

3.29 (1.47-7.34)

2.12 (0.64-7.00)

0.52 (0.07-3.77)

Referent

<0.01

0.22

0.51

Married No

Yes

67

35

44.8

37.1

1.00

0.79 (0.41-1.51)

Referent

0.47

Children None

1 or More

91

13

44.0

30.8

1.00

0.63 (0.23-1.77)

Referent

0.38

Entry Program

Accounting/Finance


Diversified

Engineering/Science

Intelligence

Language

Law


11

4

34

12

11

8

16

3

54.5

25.0

41.2

66.7

36.4

37.5

43.8

33.3

1.00

0.29 (0.03-2.38)

0.61 (0.23-1.59)

1.44 (0.50-4.16)

0.57 (0.16-2.00)

0.48 (0.12-1.91)

0.64 (0.22-1.91)

0.49 (0.06-4.07)

Referent

0.25

0.31

0.50

0.38

0.30

0.42

0.51

Educational Level

Bachelor Degree

Master’s or Doctoral

Degree

44

60

43.2

41.7

1.00

0.96 (0.53-1.75)

Referent

0.90

Foreign Language No

Yes

56

48

41.1

43.8

1.00

1.09 (0.60-1.97)

Referent

0.78


Yes

86

18

46.5

22.2

1.00

0.41 (0.15-1.14)

Referent

0.09

Law Enforcement

Experience

No

Yes

84

20

45.2

30.0

1.00

0.59 (0.25-1.41)

Referent

0.24

Dominate Hand

Right

Left

Ambidextrous

93

5

1

39.8

80.0

100.0

1.00

2.73 (0.97-7.68)

----

Referent

0.06

-----

g. Multivariate Analysis of Injury Risk Factors.

(1) Table 43 shows the results of the multivariate backward stepping Cox regression

examining associations between any injury and potential risk factors among the men.

Independent risk factors for injuries included older age, slower sprint speed, slower 1.5-mile run

time, having not smoked 100 cigarettes in a lifetime, less active self-rating of physical activity

relative to peers, lower and higher frequency of aerobic training, having a prior upper limb

injury, having a prior upper limb that did not allow returning to normal physical activity, and

having knee pain that limits physical activity.


64

Table 43. Multivariate Analysis of Potential Injury Risk Factors in New Agent Men Variable Level of Variable N Hazard Ratios

(95%CI)

from Cox

Regressions

p-value

(from Wald

statistic)

Age 24-30 years

30-37 years

187

238

1.00

1.70 (1.20-2.42)

Referent

<0.01

300-Meter Sprint 40-44 seconds

44-46 seconds

47-48 seconds

49-55 seconds

122

132

108

63

1.00

1.34 (0.84-2.16)

1.84 (1.31-3.00)

1.75 (1.01-3.02)

Referent

0.22

0.01

0.05


10.36-11.10 minutes

11.11-11.64 minutes

11.65-15.02 minutes

108

107

104

106

1.00

1.14 (0.67-1.94)

1.84 (1.11-3.04)

1.95 (1.19-3.20)

Referent

0.63

0.02

<0.01


in Lifetime

No

Yes

351

74

1.00

0.42 (0.25-0.71)

Referent

<0.01

Q19. Self Rating of

Physical Activity

Less Active

About the Same

More Active

6

30

389

6.68 (2.52-17.70)

0.56 (0.27-1.17)

1.00

<0.01

0.12

Referent



≤ 1 time/week

2-4 times/week

≥5 times/week

2

263

160

4.58 (0.97-21.71)

0.69 (0.49-0.97)

1.00

0.06

0.03

Referent



Upper Limb Injury

No Injury

No

Yes

246

11

168

1.00

3.36 (1.48-7.62)

1.41 (1.00-2.00)

Referent

<0.01

0.05

Q34. Have Knee Pain

Limiting Activity Sometime

No

Yes

313

112

1.00

1.84 (1.28-2.64)

Referent

<0.01

(2) Table 44 shows the results of the multivariate backward stepping Cox regression

examining associations between any injury and the potential risk factors among the women.

Independent risk factors for injuries included slower 1.5-mile run time, reporting back pain that

limited physical activity, and left handedness.

Table 44. Multivariate Analysis of Potential Injury Risk Factors in New Agent Women Variable Level of Variable N Hazard Ratios

(95%CI)

from Cox

Regressions

p-value

(from Wald

statistic)


12.07-12.95 minutes

12.96-14.92 minutes

34

32

32

1.00

1.00 (0.46-2.18)

1.95 (0.97-3.93)

Referent

0.99

0.06

Q35. Have Back Pain

Limiting Activity Sometime

No

Yes

78

20

1.00

2.37 (1.27-4.43)

Referent

<0.01

Dominate Hand Right

Left

93

5

1.00

2.52 (0.89-7.15)

Referent

0.08


65

7. DISCUSSION. The present project complements the earlier retrospective investigation1 of

injuries and physical fitness among FBI new agents by prospectively examining injury rates and

also examining a greater number of potential injury risk factors. In the previous investigation,1

the only risk factor examined was physical fitness. In addition to physical fitness, the present

investigation also examined age, height, weight, BMI, tobacco use, prior physical activity, self-

assessed fitness, prior injury, menstrual history, and demographic variables. Compared to the

retrospective investigation, the present investigation included a much smaller number of new

agents which limited statistical power, especially among women. Despite this, a number of

additional injury risk factors were identified and these offer further suggestions for injury

prevention in new agent training. Before these risk factors are discussed, similarities and

differences in the injury and fitness data in the retrospective1 and prospective investigations are

considered, along with a comparison of injury rates among new agent and military trainees.

a. Comparison of Injury Data in Retrospective and Prospective Investigations.

(1) The previous retrospective investigation1 reported an overall injury incidence (any

injury) of 40% for men and 45% for women for training during the FY03 through FY08 period.

In the present investigation, the overall injury incidence was slightly lower, 35% for men and

42% for women. Figure 1, which shows injury incidence over the FYs, shows that the injury

incidence in the current investigation is within the range of the yearly injury rates seen in the

past. The reason for the lower injury incidence in FY 08 is not clear. Nonetheless, the present

cohort appears to be representative with regard to the overall incidence of injury.


66

0

10

20

30

40

50

60

70

FY

03

FY

04

FY

05

FY

06

FY

07

FY

08

Cu

rren

t

Inju

ry I

nci

den

ce (

%)

Men

Women

Figure 1. Incidence of Any Injury from Retrospective Data (FY03 to FY08) and Current

Prospective Data

(2) The present prospective investigation improved on the retrospective investigation by

accounting for time at risk. The retrospective analysis assumed that all agents completed the

training course, but obviously some new agent trainees did not. Analyses in the retrospective

investigation suggested that the error induced by the drop-outs was small since only 3-4% of new

agents permanently dropped out of the course. The present investigation had a similar drop out

incidence since conversions, dismissals, and resignations accounted for 4% (n=22) of the initial

cohort (some of the recycle-outs may have permanently dropped out of the course later but we

did not track these). Nonetheless, the present prospective study provides a more accurate

estimate of injury risk in the time period examined.

(3) We found more specific diagnoses in the medical records in the present prospective

investigation compared with the previous retrospective investigation.1 For example, in the

retrospective investigation, traumatic musculoskeletal pain (not otherwise specified) accounted

for 27% of the diagnoses while in the present study this category was only 12% of the diagnosis.

The traumatic musculoskeletal pain category involved encounters where an individual reported

pain in a specific musculoskeletal location but no specific diagnosis was found in the medical

record. The higher diagnostic specificity in the prospective study was likely due to the presence

of a full-time, on-site physician who was at the FBI Health Clinic for the entire investigation and


67

performed many of the diagnoses. In the retrospective investigation, a physician was on-site for

only a small time. Table 45 compares the most common injury diagnoses in the retrospective

and prospective investigations.

Table 45. Comparison of Most Common Diagnosis in Retrospective and Prospective

Investigations Retrospective Investigation, FY00-08

(% of all injuries)

Prospective Investigation

(% of all injuries)

Joint Injury (traumatic) 10 14

Muscle Injury (traumatic) 11 12

Musculoskeletal Pain (traumatic) 27 12

Abrasions/Lacerations 9 11

Contusions 9 11

Total Accounted For 66 60

(4) In the present prospective study, the largest number of specific diagnoses (i.e.,

exclusive of musculoskeletal pain) was for strains, sprains, contusions, and abrasions/lacerations.

These are common injuries in physically active groups of individuals who are involved in

running, sports, recreational activities, and military training.12, 13, 170-178

In the prospective study,

there were few cases of more serious traumatic injuries such as bone fractures, dislocations, and

subluxations; these totaled only 4% of all injuries. In studies of runners and collegiate sports

athletes, fractures, subluxations, and dislocations have accounted for 3% to 13% of all

injuries.170, 172, 173, 175-178

Less serious traumatic injuries like abrasions/lacerations accounted for

11% of all injuries and contusions accounted for 11% also. This is comparable to finding in the

sports literature in which abrasions and lacerations accounted for 8% to 11% of all injuries,173,

176, 178 and contusions accounted for 6% to 24% of all injuries.

172, 175, 177, 178 With regard to

specific overuse injuries, tendonitis accounted for less than 2% to 3% of FBI new agent injuries

but in runners, college athletes, and military trainees this injury accounts for 5% to 12% of all

injuries.13, 170-172, 174, 176

It appears that more serious injuries are less common in FBI new agent

training than the incidence seen in other groups of active individuals.

(5) Among new agent trainees in the prospective investigation, only 14% of injuries were

classified as overuse, with 68% classified as traumatic. This was similar to the retrospective

investigation1 which found 15% and 70% of injuries were classified as overuse and traumatic,

respectively. In contrast to this finding, in military basic training overuse-type injuries account

for about 75% of all injuries.16

This difference might be accounted for by contrasting the

patterns of activity in these two types of training. In US Army Basic Combat Training (BCT),

recruits perform virtually all physical training as a group regardless of fitness level. During

running activities, individuals of similar fitness run together179

but with this one exception, all

other physical and operational training is conducted together, regardless of fitness level. The

basic rationale is to keep the recruits together to build fitness and operational competence while

at the same time developing morale (esprit de corps) and teamwork, all under the guidance of a


68

knowledgeable leader, the drill sergeant. In contrast, FBI new agent trainees perform most of

their physical fitness training on their own. There are 91 hours (out of 850 hours) of physical

training, but most of this is in defensive tactics with only about 11 hours involving group

physical fitness training which includes the PFT. It is likely that the individualized physical

training performed by FBI new agents resulted in fewer overuse injuries since the intensity,

frequency, and duration is determined by the individual agent. For example, an agent should

voluntarily skip a training day or reduce the amount of exercise if the individual was feeling pain

or other symptoms that might suggest that might suggest impending injury. Further, defensive

tactics training, comprising much of group physical training, involved activities like boxing,

subduing suspects (wrestling, grappling, handcuffing), and defensive movements which likely

leading to a higher incidence of traumatic injuries. In fact, over half of the injuries in FBI new

agent training occurred in association with defensive tactics and only about 20% to 25% in other

physical training.

(6) Because of the potential consequences and past history at the FBI Academy, there was

high interest among the FBI Academy leadership in rhabdomyolysis. No cases were diagnosed

during the current prospective project. In the retrospective project,1 the overall number of new

cases was 14 among 4767 new agents for an incidence of 2.9 cases/1,000 new agents. Thus,

only 1 or 2 cases might have been expected among the 531 new agents who participated in the

prospective project. In the retrospective investigation, no cases of rhabdomyolysis were found in

4 of the 9 FYs examined and most cases (8 of 14) occurred in a single FY, FY08. Further,

physical trainers and the medical staff were well aware of the high number of cases in FY08 and

may have taken steps to minimize the possibility of more cases. Nonetheless, physical trainers

and the medical staff should be advised to remain vigilant for signs and symptoms of

rhabdomyolysis, as defined in the Background section of this paper. Medical staff should be

prepared to rapidly treat cases, as outlined in the Background section.

(7) Table 46 compares the proportion of injuries occurring in various anatomical locations

in the retrospective and prospective investigations. With regard to general body areas, the

prospective investigation had a slightly higher proportion of head injuries compared with the

retrospective investigation.1 At specific anatomical locations, the proportion of injuries in the

retrospective and prospective investigations was similar for all areas except the head and fingers

(the head area excludes the face, ears and eyes which are counted separately).


69

Table 46. Comparison of Anatomic Locations in Retrospective and Prospective Investigations Anatomical Areas Retrospective Investigation,

FY00-08

(% of all injuries)


(% of all injuries)

General Areas

Head 16 20

Upper Body 42 43

Lower Body 37 32

Unknown/Other/Multiple 5 5

Specific Areas

Knee 10 10

Shoulder 8 8

Face 7 6

Eyes 7 8

Ankle 6 5

Chest 4 4

Fingers 3 7

Head 2 5

(8) The incidence of closed head injuries/concussions was much higher in the prospective

investigation compared with the retrospective investigation. In the prospective investigation

there were 11 cases out of 534 new agents for an incidence of 2.1%. In the retrospective

investigation there were 19 cases among 4,767 new agents for an incidence of 0.4%. The risk

ratio (prospective/retrospective) was thus 5.17, 95% CI=2.47-10.80. As a proportion of all

injuries, close head injuries/concussions accounted for 11% and 0.4% of all injuries in the

prospective and retrospective investigations, respectively. In 8 of the 11 (73%) prospective

closed head injury/concussion cases, bull-in-the-ring the activity listed in association with the

injury. In the other 3 prospective cases (27%), boxing was the activity listed (it was not clear

whether this meant boxing alone or as part of bull-in-the-ring). In conversations with the on-site

physician and the Physical Training Unit staff it was found that stricter criteria were being used

to define concussion/closed head injury during the prospective study. The criteria were from the

Brain Trauma Foundation (www.braintrauma.org <http://www.braintrauma.org/> ), although

other sources were also consulted. Both the medical staff and Physical Training Unit were likely

to remove new agents from activities (especially boxing) if the signs/symptoms were noted.

Thus, the higher incidence was likely due to better awareness and improved surveillance.

(9) In the prospective investigation, 32% of injury cases involved the lower body and 43%

involved the upper body, about the same as in the retrospective investigation, as shown in Table

46. In sports and recreational activities, the lower body is the site of over 50% of injuries and up

to 84% of all injuries.85, 173, 177, 180

In military basic training, 77% to 88% of injuries are to the

lower body13, 16

and in military infantry operational training about 50% to 60% of injuries

involve the lower body.181-183

Much of military training involves the lower body in activities like

sprinting, running, patrols on foot while carrying equipment, walks to training area, drill and

ceremony, and the like. Much of FBI new agent training in defensive tactics training involves

the upper body in boxing and suspect apprehension (handcuffing, subduing, wrestling). In a


70

study of active law enforcement officers combined with police trainees,4 the major injury sites

were hand/wrist (23%), back (16%), and knee (10%). This compares with 14%, 6%, and 10%,

respectively, in the present study.

(10) Figure 2 compares the proportion of injuries associated with defensive tactics,

physical fitness training and physical fitness testing in the retrospective and prospective

investigations. In both investigations these were the three leading activities associated with

injury. The proportion of injuries associated with physical fitness training has declined over the

years while that associated with defensive tactics increased from FY00 to FY05 and has

plateaued since FY05. The current prospective investigation has the highest proportion of

injuries due to defensive tactics in the past FYs.

0

10

20

30

40

50

60

70

FY

00

FY

01

FY

02

FY

03

FY

04

FY

05

FY

06

FY

07

FY

08

Cu

rre

nt

Pro

port

ion

of

All

In

jurie

s (%

) Defensive Tactics

Fitness Training

Fitness Testing

Figure 2. Proportion of New Agent Injuries Associated with Defensive Tactics Training,

Physical Fitness Training, and Physical Fitness Testing from the Retrospective Data and Current


(11) From an injury-prevention standpoint, the most important information in the medical

records is the activity associated with the injury. In some cases, the injury will be of the overuse

type and have an insidious onset making it difficult to link to a specific event. In both the

retrospective1 and prospective projects we could often link the injuries to a specific training

activity, but the recording of activities associated with injury was not standardized in the medical

records so any accounting of activities associated with the injury was incomplete. For example,


71

although we could estimate that about 60% of the prospective injuries were associated with

defensive tactics, often the medical records provided no further information. On other occasions

the record might list “bull-in-the-ring” and, since we knew this was part of defensive tactics

training, we could include it there. However, many times just “defensive tactics” was listed with

no further information.

(12) To improve collection of information on injury mechanisms, information should be

obtained on both the activity associated with the injury and the mechanism of injury.

Mechanism notes should include exactly how the injury occurred. An example is a simple note

like “another student fell on patient’s outstretched arm during grappling in defensive tactics”.

This includes both the training activity (defensive tactics, grappling) and the mechanism of

injury (body fell on arm).

(13) Given the emphasis in the curriculum and the physical involvement, it is reasonable

that most of the injuries would occur during defensive tactics and physical training. We

observed that many safety features were in place at the FBI academy during defensive tactics

training and the staff was knowledgeable in this area. Examples in boxing are the use of boxing

gloves, headgear, and mouthpieces. During other defensive tactics training, new agents were

provided practice on cushioned mats, which offered some protection during falls and takedowns.

Nonetheless, defensive tactics should be further examined to determine whether additional safety

measures can be put in place.

(14) Table 47 compares the proportion of dispositions in the retrospective and prospective

investigations. In the prospective investigation, a smaller proportion of new agents was referred

for consults. This is likely due to the presence of an on-site physician who could perform

diagnosis and provide or delegate appropriate treatment.

Table 47. Comparison of Dispositions in Retrospective and Prospective Investigations Retrospective Investigation, FY00-08

(% of all injuries)


(% of all injuries)

Return To Duty 42 67

Limited Duty 7 8

Consults 50 21

Other/Unknown 1 4

(15) We found that in 9% of the new injury cases, injury-related data were only available

from the CA-1s. For these cases, no encounters were listed in the medical database, only on the

CA-1s. These may have been injury cases that occurred after hours or on the weekend when the

clinic was closed; the new agent had to seek medical care elsewhere. Also, these may have been

emergency cases where an emergency medical technician was called in and no record was made

in the clinic.


72

b. Comparisons of FBI and Military Injury Incidence.

(1) Comparisons of overall injury incidence between FBI new agent trainees with other

physically active groups are complicated by the different time periods over which the injury data

were collected (i.e., different time-at-risk for injuries). One might assume that adjustment for

time at risk by equating time periods would account for this. For example, FBI injury incidence

might be adjusted to a monthly rate by dividing the injury incidence by 5.25 (21 weeks are 5.25

months). However, this assumes that injuries are equally distributed across the training period.

This is not the case for FBI new agent training, as there are more injuries earlier in training. For

example, in this prospective study 45% of injury cases occurred during the first 6 weeks of

training and 6 weeks is about 30% of the total training period. Thus, comparisons of monthly

injury incidence rate in groups with longer training times (i.e., FBI new agent training) will tend

to underestimate the monthly injury incidence rate when compared to groups with shorter

training periods (e.g., military basic training).

(2) A more appropriate comparison may be to look at cumulative injury incidence in

comparable time periods. Thus, injury incidences were calculated for the first 6, first 9, and first

12 weeks of FBI new agent training in both the retrospective and prospective investigations.

This allowed comparisons with injury incidence in Air Force, Army and Marine Corps basic

training which were 6, 9, and 12 weeks, respectively (from Table 1). Table 48 shows these

calculations and comparisons. It can be seen that injury incidences among male new agent

trainees is generally slightly lower or within the lower range of men in basic military training.

On the other hand, women in new agent training have a much lower injury incidence than

women in basic military training. The lower injury rate may be related to the higher fitness level

of the female FBI new agent trainees (compared with military women) as discussed below.

Table 48. FBI New Agent Training Injury Incidence Compared with the Basic Military Training

at the Same Time Intervals

FBI New Agent Training

Injury Incidence (%)

Range of

Air Force

Injury

Incidence

(%)

(6 weeks of

training)

Range of

Army

Injury

Incidence

(%)

(9 weeks of

training)

Range of

Marine

Corps Injury

Incidence

(%)

(12 weeks

of training)

6 Weeks

9 Weeks

12 Weeks

Men

Retrospective Investigation 17 23 29 17-28 14-37 25-60

Prospective Investigation 15 18 23

Women

Retrospective Investigation 26 31 36 38-47 36-65 41-53

Prospective Investigation 24 30 33


73

c. FBI New Agent Fitness Compared with Other Groups.

(1) Table 49 shows PFT values in the prospective investigation and compares FBI new

agent trainees with groups of military basic trainees and other law enforcement officers. Only

test events that were conducted in a manner identical to the FBI PFT events are included in the

table. No comparable data were available on the 300-meter sprint. Average pull up performance

of the male FBI new agent trainees was identical to that of Marine recruits30

and Canadian

policemen50

and higher than that of Louisville police recruits45

and Finnish police.51

Average

pull-up performance of the female FBI new agent trainees was identical to female Canadian

police.50

Average push-up and sit-up performance of male FBI new agent trainees was slightly

lower than that of Canadian police recruits and Canadian College students52

but higher than that

of longer-serving Canadian police50

and North Carolina law enforcement trainees.47

Average

push-up performance of female FBI new agent trainees was lower than that of female Canadian

police recruits52

. Average sit-up performance of female FBI new agent trainees was higher than

that of female Canadian police or police recruits52

and also higher than North Carolina law

enforcement trainees.47

Average time of male FBI recruits on the 1.5-mile run was faster than

that of Marine Corps recruits,30

Air Force recruits,23

and Canadian police recruits/college

students.52

Performance on the 1.5-mile run was much higher for female new agents that for

female Marine Corps recruits,30

Air Force recruits,23

or Canadian police recruits/college

students.52

On the whole, the PFT performance of FBI new agents was similar to or higher than

that of other military and law enforcement groups. Running performance of female FBI new

agent trainees was especially fast, relative to other groups.

Table 49. Comparison of Fitness Measures of FBI New Agent Compared with Military Basic

Trainees and Other Law Enforcement Groups

Group Gender (n) Pull-Ups

(repetitions)

Push-ups

(repetitions)

Sit-Ups

(repetitions)

1.5-mile

Run (min)

FBI New Agent Trainees (Prospective

Investigation)

Men (n=426) 8±4 37±9 44±5 11.1±1.0

Women (n=105) 1±2 17±9 42±7 12.5±1.2

Marine Recruits30 Men (n=782) 8±5 ND ND 11.3±1.1

Women (n=568) ND ND ND 13.8±1.2

Air Force Recruits23 Men (n=1,713) ND ND ND 12.9±1.8

Women (n=682) ND ND ND 16.7±2.7

Canadian Police50 Men (n=78) 8±4 29±12 33±8 ND

Women (n=27) 1±2 ND 38±9 ND

Canadian Police Recruits & College Students52 Men (n=21) ND 39±14 47±10 11.4±2.1

Women (n=27) ND 21±11 43±13 13.3±3.0

Louisville Police Trainees45 Men (n=54) 5±3 ND ND ND

North Carolina Law Enforcement Trainees47 Men (n=136) ND ND 38±9 ND Women (n=33) ND ND 31±7 ND

Finnish Police51 Men (n=90) 5±3 ND ND ND

ND=No Data reported


74

(2) Aerobic capacity (VO2max) of new FBI recruits can be estimated from 1.5-mile run

times by using available equations. VO2max is the criterion measure for aerobic capacity. It is

the highest rate at which oxygen can be taken up and used by the body during longer-term

exercise184

like running. The faster the rate at which oxygen can be used, the faster the rate at

which energy can be produced and the higher the rate at which longer-term physical activity (like

running) can be performed.

(3) Five equations for predicting VO2max from 1.5-mile run times are presented in Table

50 along with some descriptive information on the subjects used to develop the equations. The

subjects used by Pollock and Wilmore185

are not clear. They only presented 1.5-mile run with

matched VO2max data and those data were used by the present authors to develop the equation.

All other studies obtained actual VO2max using a graded running treadmill test with expired gas

measurement, then had the same individuals complete a maximal effort 1.5-mile run. Equations

were established using linear regression. Only two equations185, 186

could be applied to the

retrospective FBI new agent data1 because some equations

187, 188 required body weight, which

was not available in the retrospective investigation.1 An additional equation

187 could be applied

to the prospective investigation because body weight was available here. One equation189

was

incorrectly printed in the article and another188

required heart rate during running (and the

regression coefficient for the heart rate factor was not provided in the article). Table 51 provides

predicted VO2max values from the predictive equations. The VO2max estimates were close,

differing by no more than 3% in either the retrospective1 or prospective investigations.


75

Table 50. Studies Proving Equations for Estimating VO2max from 1.5-Mile Run Time Study

(Reference

Number)

Subject data Measured

VO2max

(ml/kg/min)

Correlation

Coefficient

Between

Run Time

&VO2max

Equation for Predicting

VO2max N, Subject Description Height

(cm)

Weight

(kg)

Larsen et al.

2002187

57 men, 55 women,

American College

Students, age 21±2 years

171±10a 72±16 a 46±7 0.86 65.40+7.707(gender,

0=women, 1=man)-0.159

(body mass, kg)-0.843

(1.5-mile run time, min)

McNaughton et

al. 1998189

32 men, Australian

physical education

college students, age 20

years

179±2 74±3 60±1 0.87 -45.851=(1.788 (1.5-mile

run time, min))

(This is obviously

incorrect, but what is in

the article)

Pollock and

Wilmore185

Not Provided

Not

Provided

Not

Provided

Not

Provided

0.91 93.37-3.89 *(1.5-mile run

time, min)b

Getchell et al.

1997186

21 female American

college students, age

20±2 years

165±6 57±8 46±6 0.92 98.3-4.182 * (1.5 min run

time, min)

George et al.

1993188

88 male and 61 female

American college

students, age 18-29

years.

Men:

178±10

Women:

173±10

Men:

74±8

Women:

60±6

Men:

52±5

Women:

43±4

0.90 88.02+3.716*(gender)-

0.1656 * (body mass, kg)-

2.767 *(1.5-mile run time,

min)-coefficient (heart

rate) aMale and female data were combined bEstimated from data provided in book

(4) Shvartz and Reibold190

provided VO2max norms based on a review of 62 studies

which included individuals aged 6 to 75 years. Seven fitness divisions were established for

different age groups based on mean and standard deviation (SD) values (±1-3 SDs, plus mean).

In the prospective investigation, the estimated VO2max of male new agent trainees (average age

31 years) placed them into Shvartz and Reibold’s “good” (third highest of seven) category

encompassing approximately the 68th

to 89th

percentile. The estimated VO2max of male FBI

new agent trainees (~51 ml/kg/min, Table 51) was the same as men entering the Army who had

an average±SD VO2max of 51±5 ml/kg/min.191

In the prospective investigation, different

VO2max estimates (44-46 ml/kg/min, Table 51) placed female new agents (average age 30 years)

in either Shvartz and Reibold’s “good” (third highest) or “very good” (second highest) category

encompassing approximately the 68th

to 97th

percentile. FBI new agent females had a higher

estimated VO2max (Table 51) compared with women entering the Army: the latter group had an

average±SD VO2max of 39±5 ml/kg/min.191

New Army recruits are younger (average age 20

years) than FBI new agent trainees and VO2max declines with age190

suggesting that the relative


76

aerobic fitness of FBI new agents might be higher than Army recruits if adjusted for age.

Further, the 1.5-mile run was administered as the third event of the PFT. It is possible that the

fatigue accumulated from the previous tests (especially from the 300-meter run) might have

affected the 1.5-mile run times; run times may be have been faster if the run test was

administered in isolation.

Table 51. VO2max of FBI New Agent Trainees Estimated from 1.5-Mile Run Times

Gender

Investigation

Predicted VO2max (ml/kg/min) Approximate

Percentile Ranking

Based on

Normative VO2max

Data190

Getchell et al.

Equation186

Pollock and

Wilmore

Equation185

Larsen et al.187

Men Retrospective 51.0 49.4 a 68th-89th

Prospective 51.9 50.2 50.7

Women Retrospective 45.2 43.9 a 68th-97th

Prospective 46.0 44.7 45.1 aEquation could not be applied to the retrospective data because body weight was not available

d. Injury Risk Factors.

(1) Age.

(a) In the prospective investigation, the age range was only 14 years, with the youngest

individual 24 years of age and the oldest, 39 years. Nonetheless, when new agents were

partitioned into those above and below 30 years of age, older male new agents were at higher

injury risk and older female new agents tended to be higher risk. These data correspond to

investigations in military basic training12, 16, 43, 58

and airborne operations192-194

which also shows

that older individuals are at higher risk of injury. However, studies of infantry Soldiers 75, 183

and

predominately infantry Soldiers195

that have shown that younger men are at higher injury risk

compared with older men. One possible explanation for the discrepancy between the new agent,

basic training, airborne, and infantry data183

might be that in the infantry, younger Soldiers may

perform more of the arduous occupational tasks and thus be more susceptible to injury than older

Soldiers, who are likely to be of higher rank and working in supervisory or staff positions. FBI

new agent training, military basic training, and airborne training, differ from the operational

infantry in that all individuals perform similar physical tasks. Under conditions where physical

activity is similar, older individuals appear to be more susceptible to injury.

(b) The reason for the higher susceptibility to injury in older individuals may have to do

with age-related changes in stem cells, declines in fitness, and/or prior injury history. First,

consider changes in stem cells. Older tissues have less regenerative capability, due at least

partially to age-related declines in the ability of resident stem cells to initiate and conduct tissue

repair.196-198

This could make older individuals more susceptible to overuse-type injuries in

which microtrauma accumulates over time and repair in the older tissue does not keep pace with


77

repeated microtraumas. In the present prospective study, only about 14% of injuries were of the

overuse type. Nonetheless, repetitive microtraumas coupled with slower repair processes may

also weaken tissue to the point where sudden energy exchanges are more likely to cause acute

(traumatic) tissue damage.

(c) Next, consider age-related declines in physical fitness. Aging results in a loss of

muscle mass, muscle strength, muscular endurance, aerobic capacity, and flexibility.199, 200

The

loss of aerobic capacity and muscular endurance can begin as early as age 25 years.200

These

age-related changes reduce absolute fitness levels and may make injuries more likely since lower

fitness has been shown to be consistently related to injury.10, 11, 13, 16, 20, 23, 31, 32, 34, 36, 42, 43, 55-57

However, in the present study older age and lower aerobic fitness were independent injury risk

factors when included in the multivariate model. Further, there was a low correlation between

age and fitness: correlations between age and performance on push-ups, sit-ups, 300-meter

sprint, and 1.5 mile run were -0.04, 0.00, 0.19, and 0.11, respectively, for the men; for women,

these correlations were 0.09, 0.16, 0.04 and 0.11, respectively. Thus, the hypothesis that age-

related declines in fitness alone account for the association between older age and injury is not

strongly supported by data from the present investigation.

(d) Finally, consider age and prior injuries. It is possible that older individuals are more

likely to have prior injuries that may make them more susceptible to future injuries. Prior

injuries have been shown to be a risk factor for new injuries in many studies.32, 95, 98, 201-209

To

examine the hypothesis that prior injuries may make older agents more susceptible to injuries in

training, self-reported prior injuries were stratified by age, as shown in Table 52. Injuries in

training were higher in the older men, regardless of whether or not they reported a prior injury

(lower or upper body). Results for the women were less clear, presumably because of the greater

variability associated with the smaller sample size, but injury-in-training risk still tends to be

higher in the older women regardless of whether or not they had a prior injury. In addition, both

older age and a prior upper limb injury that still interfered with normal activity were both

independent risk factors for training-related injuries in the multivariate analysis. Thus, the

hypothesis that prior injury may make older individuals more susceptible to future injuries is not

supported in FBI new agent training.


78

Table 52. New Agent Injuries in Training Stratified by Self-Reported Prior Injury and Age

Gender

Self-

Reported

Injury Type

Response Category 24.1-29.9 Year Olds 30.0-38.6 Year Olds p-

valuea

Risk Ratio-

Older/Younger

(95%CI) N % Injured

in Training

N % Injured

in Training

Men

Lower Limb

Injury

No Reported Prior Injury 73 21.9 94 35.1 0.06 1.60 (0.96-2.67)

Reported Prior Injury 115 29.6 144 45.8 <0.01 1.55 (1.11-2.16)

Upper Limb

Injury

No Reported Injury 113 23.9 135 37.0 0.03 1.55 (1.04-2.30)

Reported Injury 75 30.7 103 47.6 0.02 1.55 (1.04-2.30)

Women

Lower Limb

Injury


Reported Injury 38 34.2 27 51.9 0.15 1.52 (0.86-2.68)

Upper Limb

Injury


Reported Injury 15 33.3 17 52.9 0.27 1.59 (0.68-3.69) aChi-square statistic

(2) Physical Fitness.

(a) In the prospective data, FBI new agent data generally showed that higher levels of

physical fitness were associated with lower levels of injury. While this was statistically

significant only for the 300-meter run and the 1.5-mile run, injury risk was still higher in the

lowest fitness quartile (men) or tertile (women) for all the fitness measures. In addition, slower

1.5-mile run time was an independent risk factor for injury in the multivariate analysis for both

men and women.

(b) Of particular interest was the association between injuries and the total PFT point

score. Both men and women who achieved at least 11-12 total PFT points were at lower injury

risk than those who scored below 10 total points. In the retrospective study1 we did not report

total points. We re-analyzed the retrospective database to examine injury risk by total PFT

points. Table 53 shows injury incidence by quartiles in the retrospective investigation.1 In

consonance with the present prospective findings, those who scored at least 11 total points had

lower risk than those who scored 10 points or below. Among the women, injury risk was further

reduced among those scoring at least 15 points.

Table 53. New Agent Injury Incidence (% Injured) by Physical Fitness Test Score in

Retrospective Investigation -4-10 points 11-14 points 15-17 points 18-36 points p-valuea

Men (n=2837) 42 31 32 32 <0.01

Women (n=774) 46 40 35 35 0.06 aFrom chi-square test

(c) The finding that FBI new agents with lower fitness levels were at higher risk of injury

agrees well with military basic training studies.10, 11, 13, 16, 20, 23, 31, 32, 34, 36, 42, 43, 55-57

However, this

finding does not agree with most studies of free living individuals79, 81-87

which generally find

the opposite, that individuals with higher fitness levels have higher injury incidence. One of the


79

common characteristics of military basic training and FBI new agent training is that individuals

perform many physical activities with their fellow trainees. In the present prospective

investigation, almost 60% of all injuries were associated with defensive tactics. All new agent

trainees perform defensive tactics together and thus are exposed to similar risks. Twenty percent

of injuries were associated with physical training in the present prospective investigation. New

agent trainees who fail the initial PFT were required to attend supervised physical training

(called “Power PT”) three times per week and these new agent trainees would likely be

performing very similar training. New agent trainees who passed the initial PFT were allowed to

perform physical training on their own. Nonetheless, the types of physical training performed by

these more fit new agents was likely similar to that of other new agents. This training likely

involved both strength and aerobic training and focused, to a large extent, on passing the second

PFT. It is possible that the relationship between low fitness and higher injury risk can be

demonstrated in basic training and in new agent training (but not in civilian groups) because in

these situations, the level and type of physical training are similar among participants.

(3) Tobacco Use.

(a) In the present study, little association was found between cigarette smoking and injury

risk among the men or women. Only 13 men and 3 women who reported smoking even one

cigarette in the 30 days before new agent training. Also, the amount of smoking reported was

small, an average of 2 cigarettes per day for the men and 6 cigarettes per day for the women.

The combination of the small number of smokers and low cigarette dosage may account for the

lack of a relationship between cigarette smoking and injury. Previous military12, 16, 43, 58, 59, 71, 108-

110 and civilian investigations

77, 111-115 have shown that higher injury risk was associated with

cigarette smoking, and that as the amount of smoking increases so does injury risk.12, 16, 43, 58, 59,

108

(b) Table 53 compares FBI new agents and military recruits22, 23, 30

on responses to

smoking-related questionnaire items. Questionnaire items were worded identically in all the

investigations. Table 53 shows that FBI new agents and military recruits smoked their first

cigarette at a similar average age. However, a much lower proportion of FBI new agents had

smoked 100 cigarettes in their lifetime. FBI new agents who did smoke did so on fewer days,

and consumed fewer cigarettes per day than military recruits.


80

Table 53. Comparison of Smoking Variables in FBI New Agents and Military Recruits (values

are mean±standard deviation or %)

Questionnaire Item

Men Women

FBI

New

Agents

Army

Recruitsa

Marine

Corps

Recruitsb

Air

Force

Recruitsc

FBI

New

Agents

Army

Recruitsa

Marine

Corps

Recruitsb

Air

Force

Recruitsc

Age Smoked First Cigarette (years) 17±3 16±3 16±3 16±3 17±3 16±3 15±3 16±3

Smoked 100 Cigarettes in Lifetime (%yes) 17 53 39 31 14 45 24 27

Days Smoked in Last 30 Days (days) 6±9 20±11 18±10 18±10 4±5 22±11 19±10 20±10

Cigarettes per Day in Last 30 Days (n) 2±3 9±8 8±12 7±8 6±8 8±6 7±7 8±7 aFrom reference 22 bFrom reference 30 cFrom reference 23

(c) The Centers for Disease Control and Prevention (CDC) found that in 2008, 26% of

men 22-44 years old and 21% of women 22-44 years old women reported smoking cigarettes.

For those with undergraduate degrees, 12% of men and 10% of women reported smoking

cigarettes. Smoking was defined as having smoked 100 cigarettes in one’s life and smoking

every day or on some days.210

Applying the CDC smoking criteria to FBI new agents, we found

that only 10 male new agents (2%) and 3 female new agents (3%) would be defined as smokers.

Studies of law enforcement officers in various cities find smoking prevalence rates ranging from

12% to 51%.88-90, 106, 107

Cigarette smoking prevalence was very low among FBI new agents

compared to the general US population and other law enforcement groups.

(d) On the other hand, self-reported smokeless tobacco use among new FBI agents was

similar to that in the general US population and among Army recruits. We found that 24 of 426

male FBI new agent (6%) and 1 of 105 female new agent (1%) reported using smokeless tobacco

in the last 30 days. Data from the National Health Interview Survey indicated that in 2000, 6%

of 25-44 year old men and 0.3% of women of all ages use smokeless tobacco on all or most

days.211

In US Army Basic Combat Training in 1998, 7% of men (16 of 221) and 1% of women

(2/183) reported smokeless tobacco use.55

In the present prospective study, smokeless tobacco

use was not associated with injury. This agrees with a previous investigations in US Army Basic

Combat Training,55

but smokeless tobacco use has been found to increase injury risk in

Norwegian basic training43

and it is a risk factor for foot blisters.138, 212

(e) Somewhat perplexing was the higher injury risk among men who reported smoking at

some point in their lives compared with those who had never smoked. Specifically, there was

lower injury risk among men who reported smoking at least 100 cigarettes in their lives

(questionnaire item number 9) or those who reported smoking at least 1 cigarette at some age

(questionnaire item number 10) (Table 39). Not smoking at least 100 cigarettes in one’s life was

an independent risk factor for injury among new agents. This is in contrast to studies among

Army,22

Marine,30

and Air Force23

recruits where men who had not smoked at least 100

cigarettes in their lives or those who and had smoked at least 1 cigarette at some age had higher


81

injury risk in training. One difference in the FBI and military studies is that few FBI new agents

are still smokers while a large proportion of military recruits continue to smoke. Many FBI new

agents may have experimented with smoking in the past but did not smoke for long. In addition

to smoking cessation, these individuals may have adopted other favorable health habits that may

have reduced injury risk in training.

(f) Of interest was the fact that cigarette smokers and non-smokers had similar level of

physical fitness as shown in Table 54. This is in consonance with Army data that shows that in

younger individuals fitness levels do not differ, but at older ages (over 40 years) smokers tend to

have lower aerobic fitness.16, 22, 112, 213, 214

Table 54. Physical Fitness in New Agent Smokers and Non-Smokers Men Women

Smokers (n=13) Nonsmokers

(n=413)

p-value Smokers (n=3) Nonsmokers

(n=102)

p-value

Push-Ups (n) 35±9 37±8 0.65 13±9 17±8 0.37

Sit-Ups (n) 44±4 44±5 0.72 38±10 42±6 0.27

300-Meter Sprint (sec) 45.6±2.5 45.9±2.4 0.66 57.0±2.6 56.1±3.0 0.61

1.5 Mile Run (min) 11.0±0.8 11.1±1.0 0.86 12.4±0.2 12.5±0.9 0.96

Total Score (points) 14.3±5.7 14.9±5.7 0.70 9.3±2.1 12.5±4.6 0.25

(4) Physical Activity and Self-Rated Fitness.

(a) Male new agent trainees were at greater injury risk if they rated themselves less

physically active than their peers, reported that they performed aerobic exercise ≤ 1 time/week,

or self-rated their endurance as less than average. Women had a similar trend for self rated

physical activity and self rated endurance but these were not statistically significant, presumably

because of the lower statistical power (fewer women in the sample); no women reported

performing aerobic exercise ≤ 1 time/week. These data are similar to those reported by Nabeel

et al.215

who indicated that Minnesota police officers who self-reported higher fitness levels or

more physically activity were less likely to report sprains, chronic pain or back pain. The data

are also in consonance with previous studies in military training which have found that there is

increased risk of injury among those who report lower self-reported physical activity relative to

peers, 12, 16, 21, 22, 30, 32, 56

or lower frequency of aerobic activity.12, 16, 22, 30

Physical activity of the

proper intensity, frequency, and duration can increase aerobic fitness, muscle strength, and

general health, and can reduce body fat.216-220

Bone mineral density is higher in physically active

individuals109, 221-223

and higher bone mineral density has been associated with greater weekly

physical activity.222

These and other factors may contribute to reduced susceptibility to injury

among more physically active individuals.224

(b) The American College of Sports Medicine (ACSM) recommends that to promote and

maintain health, men and women 18-65 years old should perform moderate intensity aerobic


82

physical activity for at least 30 minutes on 5 days each week, or vigorous activity for at least 20

minutes on 3 days each week.225, 226

To improve aerobic fitness (VO2max), long-term physical

activity should be conducted at intensities between 50 to 90% of VO2max.46, 227

Vigorous

physical activity that promotes fitness would be most advantageous for FBI new agents because

higher levels of fitness are associated with higher levels of occupational performance.228-230

Data

from the Behavioral Risk Factor Surveillance Study indicated that in 1998, only about 5% of

Americans reported that they performed the ACSM recommended amount of vigorous

activity.231

ACSM also recommends that to promote and maintain good health, activities that

increase muscular strength and endurance should be performed on two or more days per week.225

(c) The questionnaire responses of new agents to items on the frequency and duration of

vigorous aerobic physical activity (Appendix C, Questions 20 and 21) were further examined. It

was found that 95% of the men (405 of 426) and 96% of women (101 of 105) reported vigorous

aerobic exercise at least 3 times per week for at least 16-30 minutes. Also, 78% of men (332 of

426) and 89% of women (93 of 105) reported vigorous aerobic exercise at least 3 times per week

for at least 31-45 minutes. With regard to weight training, the questionnaire responses to the

item on the frequency of weight training were examined (Appendix C, Question 22). It was

found that 78% of men (332 of 426) and 77% of women (81/105) reported weight training at

least twice per week in the two months before new agent training. Thus, a large proportion of

new agents report favorable amounts of physical activity in the 2 months before entering the FBI

Academy.

(d) Of interest was the finding that men who reported performing aerobic training 2-4

times per week were at lower injury risk than those who reported performing aerobic training ≤

1 time/week or ≥5 times/week. Previous studies have shown that both low12, 16, 22, 23, 30

and

high17, 60, 93-95, 99, 232, 233

levels of aerobic exercise will increase injury risk. It is possible that men

who had a high frequency of physical activity prior to new agent training continued that level of

aerobic activity while in new agent training, although this is speculative. If this was the case,

this activity, combined with the required defensive tactics and other physical events, would have

increased exposure to potentially injury-producing events. The present findings suggest that

leaders should recommend a moderate frequency of vigorous aerobic activity (about 4 times per

week) prior to new agent training.

(5) Prior Injury.

(a) Male FBI new agents who reported a prior upper or lower limb injury were at higher

injury risk. If the new agent reported that the prior injury prevented normal activity for 1 week,

or if they were not able to eventually return to 100% of normal activity, injury risk in training

was further elevated compared with those who did not report these limitations. In addition, not

returning to full activity after an upper limb injury was an independent risk factor for injury.


83

Much of defensive tactics training involved upper body physical activity and those with upper

body limitations may be more susceptible to injury during this training. Other studies of military

groups,202, 203, 207

athletes,95, 98, 204-206, 208, 209, 234

and industrial workers201

have reported that prior

injuries were associated with current injuries, especially if an injury had occurred in the

preceding year.95, 98, 205, 208, 209

Many injuries may be chronic or recurrent, accounting for at least

a part of this relationship.

(b) Table 55 shows the proportion of individuals who reported prior injuries just before

FBI new agent training or military basic training.22, 23, 62

New agents reported a much higher

incidence of prior lower limb injury compared with the military groups. The average age of the

FBI new agents was about 30 years while the average age of the military groups ranged from 20

to 23years. The older age of the FBI new recruits may account for the higher prevalence of

lower limb injury since FBI new agents would have more time at risk for injury.

Table 55. Proportion (%) of FBI New Agents and Military Recruit Reporting a Prior Lower

Limb Injury Men

(% Reporting Prior Lower Limb Injury)

Women

(% Reporting Prior Lower Limb Injury)

FBI New Agents 61 62

Army Recruits22 15 14

Marine Recruits62 12 22

Air Force Recruits23 20 21

(6) Foot, Knee, and Back Pain Limiting Activity. Both men and women who self-

reported foot, knee or back pain limiting activity tended to have elevated injury risk. This was

statistically significant for foot and knee pain among the men and for back pain among the

women, but reported pain in any of these areas tended to increase injury risk. In addition, among

the men, knee pain that limited activity and, among the women, back pain that limited activity

were independent risk factors for injury. It might be useful to screen prospective new agents on

these or similar questions to further determine the nature of the limiting pain. Prophylactic

measures might be considered to reduce the risk of injuries in training. For example knee

bracing has been shown to reduce the incidence of sports injuries.235-237

(7) Injuries and Demographics.

(a) Men who were parents were at higher injury risk. It is possible that age confounded

the relationship between injuries and parenthood and this was further explored. Of the men ≥30

years of age, 77% (141 of 183) had children and 23% (42 of 183) did not (p<0.01). Men without

children had an average±SD age of 29.7±2.9 years old while those with children had an

average±SD age of 32.5±2.9 years old (p<0.01). Table 56 shows that when men of similar ages

were compared, injury incidence was similar among men with and without children. Finally,

when parenthood and age were included in the multivariate Cox regression analysis, only age


84

was retained in the final model. Thus, the association between injuries and parenthood was

likely due to the older age of those who were parents.

Table 56. New Agent Injuries in Training Stratified by Age and Parenthood (Men Only)

No Children Children p-

valuea

Risk Ratio-

Children/No Children

(95%CI) n Injured in

Training

(%)

n Injured in

Training

(%)

24.3-29.9 Years Old 146 27.4 42 23.8 0.64 0.86 (0.48-1.59)

30.0-37.0 Years Old 95 36.8 141 44.4 0.28 1.19 (0.86-1.65) aChi-square statistic

(b) Hispanic women were at higher injury risk than White or Black women. Hispanics

have the highest rates of injury-related deaths among all ethnic groups in the United States but

these deaths are predominantly male and associated with Hispanics holding high risk jobs,

especially in the construction industry.238, 239

Table 57 shows a comparison of physical

characteristics and physical fitness of female new agents by race. While there was little

difference in fitness among the racial groups, Hispanic women were shorter and tended to weigh

less than women in other racial categories. The smaller size of the Hispanic women may have

increased their injury risk, but neither height nor weight alone were injury risk factors. It is not

clear why the Hispanic women were at higher injury risk.

Table 57. Comparison of Physical Characteristics and Physical Fitness by Race (Women Only) White (n=76) Hispanic (n=9) Asian (n=6) Black (n=5) p-valuea

Age (yrs) 29.5±3.2 29.8±3.0 30.5±2.7 31.3±2.2 0.66

Height (inches) 65.7±2.6 63.3±1.5 64.5±2.3 66.6±3.6 0.04

Weight (lbs) 136.5±17.2 126.8±14.8 138.0±24.8 145.2±9.1 0.26

BMI (kg/m2) 22.2±2.1 22.2±1.8 23.2±3.0 23.2±2.7 0.56

Push-Ups (reps) 16±8 16±6 16±4 20±9 0.83

Sit-Ups (reps) 41±6 39±7 41±5 43±6 0.63

300-m Sprint (sec) 56.0±3.1 56.7±2.3 57.0±2.8 54.0±2.3 0.37

1.5-Mile Run (min) 12.4±0.9 12.8±0.6 13.0±1.0 13.0±0.7 0.12

Total Score (points) 12.8±4.8 10.2±3.1 9.8±3.9 14.0±5.1 0.18 aFrom one-way analysis of variance

(d) Women with military experience were less likely to get injured than women without

military experience. It is possible that women with military experience had higher levels of

fitness and/or performed more physical activity as a result of their military experience.

However, this hypothesis was not supported by the data. As shown in Table 58, former military

women had PFT test scores similar to their counterparts without military experience. Also,

former military women and those without military service reported similar exercise and sports

training frequencies as shown in Table 58. Thus, the hypothesis that former military women

were more physically fit or physically active relative to women without military experience was

not supported. It is not clear why former military women were less likely to be injured.


85

Table 58. Initial Fitness Scores of New Agent Women Based on Military Experience Push-Ups (n) Sit-Ups (n) 300-Meter Sprint (sec) 1.5-Mile Run (min) Total Score (Points)

Military Experience (n=18) 17±9 43±6 56.5±2.9 12.4±0.6 12.7±4.7

No Military Experience (n=86) 16±7 41±5 56.1±3.0 12.5±1.0 12.3±4.6

p-valuea 0.60 0.22 0.58 0.78 0.74 aFrom independent sample t-test

Table 59. Exercise Frequency of New Agent Women Based on Military Experience Frequency

(times/week)

Military Experience (%)

(n=18)

No Military Experience (%)

(n=86)

p-valuea

Aerobic Training 2-4/week

≥5/week

66.7

33.3

50.0

50.0

0.20

Weight Training ≤1/week

2-4/week

≥5/week

22.2

72.2

5.6

23.3

69.8

7.0

0.97

Sports ≤1/week

2-4/week

94.4

5.6

84.9

15.1

0.28

(e) Finally, women who were left handed were more likely to get injured and this was an

independent risk factor for injuries in the multivariate analysis. Previous literature has supported

the concept that left-handed individuals are more susceptible to injury.240, 241

One hypothesis to

account for this relationship is that the design of environments, tools, machines and the like favor

the right-handed majority. Left-handed individual must use their less favored hand to perform

tasks, adopt unfavorable postures, and/or generally function in environments that place them in

less than optimal positions compared with their right-handed peers.

e. Limitations.

(1) Injury diagnoses were limited to descriptions in the medical records. Many of these

did not involve diagnostic tests that would have provided definitive diagnoses. Further, 9% of

all injuries were obtained from CA-1s alone indicating that some injuries were not captured in

the medical record database. However, inclusion of the CA-1 data made the injury capture more

comprehensive than in the retrospective investigation. The injury incidence, injury diagnoses

and anatomic locations in the retrospective and prospective investigations were similar which

suggests the findings are reliable. The data provide a representative look at medical encounters

and shows a high incidence of strains, sprains, contusions and lacerations which are common

injuries in physically active populations.12, 13, 170-178

(2) This investigation identified a number of risk factors for injuries in new agent training.

However, this analysis identifies only associations between injuries and other factors; cause-and-

effect relationships are not implied. This is illustrated by the association between parenthood

and injuries which was found to be confounded by age. Further, statistical power was limited in

analyses involving the women because of the small number.


86

(3) Data on tobacco use, physical activity, prior injury, and other questionnaire variables

were based on self-reports which could be subject to recall bias. Nonetheless, the data on

physical activity and prior injury support prior findings in military and other groups. Further,

recall periods for many questions were limited to 30-60 days which has been shown to improve

the validity of the data.242-244

The small number of tobacco users, although favorable from a

health perspective, limited the ability to find associations between tobacco use and injury, if

indeed such a relationship exists among FBI new agents.

8. RECOMMENDATIONS. The recommendations here combine information from both the

retrospective and prospective investigations so that a single document contains them both.

Where the recommendation stems from the retrospective investigation this is stated.

a. New agent trainees should be encouraged to arrive at the FBI Academy with an entry

level PFT score of 12 for men and 15 for women. Scores below these levels were associated

with higher injury risk, while scores above these levels were associated with lower injury risk.

Encouraging a high level of aerobic fitness appears to be of particular importance since this was

an independent injury risk factor.

b. Encourage a moderate amount of aerobic exercise prior to and during new agent

training. Over 95% of men and women reported performing at least the minimal recommended

amount of vigorous aerobic activity and over 75% reported the recommended frequency of

weight training. Results from the present prospective investigation suggest that either too much

or too little aerobic exercise prior to new agent training increases injury risk and this is supported

by the medical literature. A recommended frequency of aerobic activity is 3-4 times/week prior

to new agent training. The present prospective investigation does not provide data that would

target a recommendation for the duration of aerobic activity to reduce injury risk but based on

recommendations from the American College of Sports Medicine the duration should be 20-30

minutes each time. Individuals should consider high-intensity interval type training since this

can also improve both aerobic and anaerobic capability as well as speed which may assist with

other activities (e.g., 300-meter run).245-248

c. Emphasize the association between low fitness and higher injury risk to new agent

trainees and to FBI field offices. In both the retrospective and prospective investigations lower

physical fitness was associated with higher overall injury risk; in the retrospective study, lower

fitness was also associated with a higher incidence of exertion and rhabdomyolysis. This

suggests that the higher the fitness level the lower the risk of injury at the FBI Academy. The

FBI literature used to prepare new agent trainees for the academy already emphasizes that

physical fitness is important for new agent trainees and provides a suggested physical training

program. Quantitative information from this project should be included in that literature.


87

d. Continue statistical analysis of PFT failure rates and continue to provide these reports

to field offices. In the retrospective study, aerobic fitness (1.5-mile run times) showed some

improvement from FY04 to FY09 and there was no decline on other PFT scores. During at least

a portion of this period (FY05-FY09), statistical reports were sent to field offices comparing

failure rates among the field offices. It is possible that this motivated field offices to more

adequately prepare new agent trainees in terms of their physical fitness. Note that the

improvement in new agent aerobic fitness is in contrast to other investigations worldwide

reporting declines in aerobic fitness over the years.

e. Examine defensive tactics training to determine whether injury risk can be reduced.

By far, the largest numbers of injuries were associated with defensive tactics training in both the

retrospective and prospective investigations. This is not surprising given the physically

aggressive nature of the training and the exposure to potential traumatic events. We observed

that many safety measures were already in place (e.g., cushioned mats, use of headgear and

mouthguards during boxing) and that the physical training staff was quite knowledgeable and

alert to safety concerns. Nonetheless, defensive tactics should be further reviewed to determine

whether additional safety measures can be implemented.

f. Improve collection of information on injury mechanisms. When a new agent trainee

presents at the clinic for an injury, information should be recorded in the medical record on both

the activity associated with the injury and the mechanism of injury. Mechanism notes should

include exactly how the injury occurred. This might include simple notes like “another student

hyperextended patient’s arm during the handcuffing exercise in defensive tactics.” This includes

both the training activity (defensive tactics, handcuffing) and the mechanism of injury

(hyperextension of the arm).

g. Use the most common injuries identified here and in the retrospective investigation to

assist in medical planning. In both investigations these injuries included strains, sprains,

contusions, and abrasions/lacerations.

h. Remain vigilant for symptoms of exertional rhabdomyolysis (ER). No cases of

rhabdomyolysis occurred during the period of this prospective investigation possibly because

physical trainers and medical staff were aware of this potential problem. ER often occurs with

excessive or unusual exercise in unconditioned individuals, especially early in training.

Physically fit individuals can also suffer from ER if they do an excessive amount of activity for

which they have not specifically trained. Although ER is an infrequent diagnosis, the Physical

Training Unit as well as medical providers should remain knowledgeable about this problem and

aware of the symptoms. New agent trainees may complain of muscle pain and limited physical

ability and may assume it is just normal delayed onset muscle soreness. Agents with persistent

symptoms or symptoms that exceed those of delayed onset muscle soreness should be escorted to


88

the medical clinic so that their symptoms can be properly diagnosed. More details on signs,

symptoms, and acute care are provided in the background section of this paper.

i. Continue investigating associations between prior injury and pain that limits activity.

(1) Self-reported prior injury in the upper or lower body was associated with

higher injury risk, especially if the new agent reported that he or she had not returned to full

activity after these previous injuries. The nature of these prior injuries (type, anatomical

location, causes, and the like) should be explored more fully to determine whether prophylactic

measures can be put in place to reduce injury risk in training.

(2) Self-reported knee, ankle and back pain that limited activity was associated

with higher injury risk. Additional information should be collected to more fully define these

problems to determine whether prophylactic measures might reduce injury risk in training. For

example, knee bracing has been shown to be an effective intervention to reduce injuries.


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American Journal of Sports Medicine. 22:12-18, 1994.

238. Howard, J., and H.H. Humphrey. Occupational injury research at NOIRS 2003. Injury Prevention. 10:195-196,

2004.

239. Cierpich, H., L. Styles, L. Davis, R. Harrison, L. Davis, D. Chester, D. Lefkowitz, D. Valiante, S. Richardson,

D. Castillo, N. Romano, and S. Baron. Work-related injury deaths among Hispanics---United States, 1992-2006.

MMWR. 57:597-600, 2008.

240. Bhushan, B., and S.M. Khan. Laterality and accident proness: a study of locomotive drivers. Laterality.

11:395-404, 2006.

241. Cohen, S. Left-handedness and accident-related injury risk. American Journal of Public Health. 79:1040-1041,

1989.

242. Zwerling, C., N.L. Sprince, R.B. Wallace, C.S. Davis, P.S. Whitten, and S.G. Heringa. Effect of recall period

on the reporting of occupational injuries among older workers in the Health and Retirement Study. American

Journal of Industrial Medicine. 28:583-590, 1995.

243. Landen, D.D., and S. Hendricks. Effect of recall on reporting of at-work injuries. Public Health Reports.

110:350-354, 1995.

244. Massey, J.T., and J.F. Gonzalez. Optimal recall period for estimating accidental injuries in the National Health

Interview Survey. Proceedings of the American Statistical Association. 18:584-588, 1976.

245. Fox, E.L., R.L. Bartels, C.E. Billings, D.K. Mathews, R. Bason, and W.M. Webb. Intensity and diatance of

interval training programs and changes in aerobic power. Medicine and Science in Sports and Exercise. 5:18-22,

1973.

246. Fox, E.L., R.L. Bartels, J. Klinzing, and K. Ragg. Metabolic responses to interval training programs of high

amd low power output. Medicine and Science in Sports and Exercise. 9:191-196, 1977.

247. Laursen, P.B., and D.G. Jenkins. The scientific basis for high intensity interval training. Optimizing training

programmes and maximising performance in highly trained endurance athletes. Sports Medicine. 32:53-73, 2002.

248. Billat, L.V. Interval training for performance: a scientific and empirical practice. Sports Medicine. 31:75-90,

2001.


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APPENDIX B.

INTERAGENCY AGREEMENT

INTERAGENCY AGREEMENT BETWEEN

THE FEDERAL BUREAU OF INVESTIGATION AND

ARMY CENTER FOR HEALTH PROMOTION AND PREVENTIVE MEDICINE

I. Purpose: This interagency agreement establishes terms and conditions of an agreement between the U.S. Army Center for Health Promotion and Preventive Medicine (CHPPM) and the Federal Bureau of

Investigation (FBI) to examine available injury data and investigate the nature of injury causation and

prevention at the FBI Academy, Quantico, Virginia. The principal focus will be the New Agent Training

Program (NATP) but the epidemiologic scope may be expanded during the course of this agreement to other

training entities by mutual agreement.

II. Authority /References:

a. DOD Instruction 4000.19, Interservice and Intergovernmental Support, 9 Aug 1995

b. USACHPPM Regulation 37-1, Reimbursable and Defense Health Program Orders, 1 Aug 2000

c. DOD Regulation 6025-18, DOD Health Information Privacy Regulation, 24 Jan 2003

d. Title 31, United States Code, Section 1535, Economy Act

e. Title 42, United Stated Code, Section 3771, Training and Manpower Development

III. Background:

The FBI's Human Resources Division, Office of Medical Services, Health Care Programs Unit (HCPU), has

requested the assistance of the CHPPM to apply their longstanding experience in injury prevention programs

in military training to the assist injury prevention in the FBI's NATP at the FBI Academy, Quantico, Virginia.

CHPPM representatives traveled to FBI Headquarters on April 24, 2008 for initial discussions. Several

questions were raised regarding the availability and accessibility of the necessary data. A meeting was

subsequently hosted by the FBI's Assistant Director, Training Division on May 19,2008. CHPPM briefed

Training Division and FBI Headquarters managers on previous experience and proposed methodology.

CHPPM personnel were provided a tour of the FBI Academy medical and training areas to further determine

the achievability of the project. CHPPM and FBI representative concluded that the project was feasible

because data since 1999 appear to be available in an isolated medical computer database.

IV. Scope:

This agreement applies to the FBI's Human Resources Division, Office of Medical Services, HCPU and

Training Division, FBI Academy, and to the CHPPM Directorate of Epidemiology and Disease Surveillance.


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The FBI will provide information and availability of students for interview so that the CHPPM can examine

injury rates, determine injury risk factors, and provide recommendations for the prevention of injuries during

the NATP. An ongoing relationship is desired to allow periodic follow-up of the results of interventions for

continued improvement and interaction with the aerobic and physical content of FBI training programs.

v. Responsibilities:

a. The FBI shall:

(1) Provide a list of all current New Agent Trainees (NATs), containing first name, last name, social

security number, and class number. Provide the names and contact information for the counselors for

these current classes.

(2) Provide access to two groups of NATs for focus group interviews lasting one hour for each group.

One group should be relatively new (2-4 weeks in training), while the other group should be nearing the

completion of training (14-17 weeks). Groups should include at least 5 NATs, but 10 NATs would be

optimal.

(3) Provide access to the paper medical records of current NATs so demographic information (race, date

of birth, height, and entry weight) can be obtained from available forms. Provide access to the

computerized medical records of the clinic from 1999 forward so that injury data can be obtained to map

rates and trends of injuries over time. Of special interest for each injury is the date of the visit, diagnoses,

anatomical location, activity associated with the injury, disposition, and class number. Provide access to

the CA-I forms so location, cause, and nature of reported injuries can be obtained.

(4) Provide all physical fitness test (PFT) scores for current NATs. Provide PFT scores for previous NA

T classes from 1999 forward, if available. These should be raw scores (number of push-ups, number of

sit-ups, run times in minutes, etc.), if available. If points are available these should also be provided.

PFT scores for weeks 1, 7 and 14 should be provided, if available.

(5) Provide access to all current classes of NATs so that a questionnaire can be administered. The

questionnaire is necessary because some potential injury risk factors can only be obtained directly from

the NATs.

(6) Provide data on injuries that result in recycling of NATs in the current classes and classes from 1999

forward, if available.

(7) Provide other available demographic data for the current classes, as available. Demographic data

might include variables like age, gender, marital status, educational level, number of dependents, and

other information. These are potential injury risk factors.

(8) Provide, to the extent possible, printed materials describing the program of instruction for firearms,

physical training, and practical applications. This would include training defining the physical activities

performed by NATs.


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b. CHPPM shall:

(1) Keep confidential all NAT personal information and not release the information to any other person or

agency without direct permission from the FBI. All medical information will be handled in compliance

with Health Insurance Portability and Accountability Act (HIPAA) standards as defined in Paragraph 7.

Only HIPAA-trained personnel will process/analyze the data.

(2) Construct a questionnaire that will ask the NATs about their fitness perceptions, physical activity prior

to the academy, tobacco use prior to the academy, and (for women) menstrual history. The FBI will review the questionnaire, provide input, and approve the final copy.

(3) Construct a database that will be used for the analysis of the data. All personal identifiers will be removed from the database before that database leaves the FBI training site at Quantico VA.

(4) Provide descriptive data (means, standard deviations, frequencies) on all variables obtained.

(5) Analyze provided data to determine injury rates, activities associated with injury, and injury risk

factors, to the extent these factors can be determined from available data.

(6) Provide both a retrospective and prospective analysis of available data. The retrospective analysis will

involve showing injury rates by year of training. The prospective analysis will include an examination of

the current classes to determine current injury rates, activities associated with injury, and injury risk

factors. All fitness, demographic, and questionnaire data will be analyzed to determine the extent to which these variables are associated with injury.

(7) Provide an analysis of injury trends over the years of available data.

(8) Provide an analysis of fitness trends over the years of available data.

(9) Provide evidence-based suggestions for reducing injuries in the New Agent Training Program.

(10) Provide a final written report and briefing within nine months after first authorized entry into the FBI

Academy to conduct the study.

VI. Resources:

The FBI shall provide to the CHPPM $65,678 to cover the costs of obtaining the data, analyzing the

data, and preparing the final report and briefing. This will be a one-time cost provided in a lump sum.

The exact breakdown of the costs in included in the attached Department of Defense Form 1144.


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VII. Privacy and Security of Protected Health Information (PHI):

a. Terms used in this section shall have the same meaning as those terms in 45 CFR part 160 and part 164

and/or DOD Regulation 6025.18-R, DOD Health Information Privacy Regulation.

b. CHPPM Obligations and Activities. The CHPPM:

(1) Will not use of disclose PHI other than as permitted or required by agreement or law.

(2) Will use appropriate safeguards to prevent use or disclose of PHI other than as provided for by this

agreement.

(3) Will implement administrative, physical, and technical safeguards that reasonably and appropriately

protect the confidentiality, integrity, and availability of the electronic PHI that is creates, received,

maintains, or transmits on behalf of the Government.

(4) Will report to the FBI any use or disclosure of the PHI not provided for by this agreement or any

security incident of which it becomes aware.

(5) Will ensure that any agent to whom it provides electronic PHI that it creates, receives, maintains, or

transmits on behalf of the Government, agrees to the same restrictions and conditions that apply through

this agreement to the CHPPM with respect to such information and will implement reasonable and

appropriate safeguards to protect it.

(6) Will mitigate, as practicable, any harmful effect known to the CHPPM of a security incident or

use/disclosure of PHI by the CHPPM in violation of the requirements of this agreement.

(7) Will provide access, at the request of the Government, in order to meet the requirement of 45 CFR

164.524.

(8) Will make any amendment(s) to PHI in a Designated Record Set that the Government directs or

agrees to pursuant to 45 CFR 164.526.

(9) Will make available internal practices, books, and records relating to the use and disclosure of PHI for

purposes of the Secretary, Health and Human Services determining the Government's compliance with

the Privacy or Security Rule.

(l0) Agrees to document such disclosures of PHI and information related to such disclosures as would

be required for the Government to respond to a request by an individual for an accounting of disclosure

of PHI in accordance with 45 CFR 164.528.

(11) Agrees to provide to the Government or an Individual information collected in accordance with the

Clause to permit the government to respond to a request by an Individual for an accounting of disclosures

of PHI in accordance with 45 CFR 164.528.


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c. Except as otherwise limited in this agreement, the CHPPM:

(1) May use or disclose PHI to perform functions or services for, or on behalf of, the FBI as specified in

this agreement, provided that such use or disclosure would not violate the Privacy Rule if performed by

the FBI. May create, receive, maintain, or transmit electronic PHI on behalf of the FBI as specified in

this agreement, provided such action would not violate the Security Rule if performed by the FBI.

(2) May use PHI for the proper management and administration of the CHPPM or to carry out the legal

responsibilities on the CHPPM.

(3) May disclose PHI for the proper management and administration of the CHPPM, provided that

disclosures are required by law, or the CHPPM obtains reasonable assurances from the person to whom

the information is disclosed that it will remain confidential and used or further disclosed only as required

by law or for the purpose for which it was disclosed to the person, and the person notifies the CHPPM of

any instances of which it is aware in which the confidentiality of the information has been breached.

(4) May use PHI to provide Data Aggregation services to the Army as permitted by 45 CFR 164.504(e)(2)(i)(B).

(5) May use PHI to report violations of law to appropriate Federal and State authorities, consistent with

45 CFR 164.522.

d. Obligations of the FBI. The FBI:

(l) Upon request shall provide the CHPPM with the notice of privacy or security practices that the FBI medical facility produces, as well as any changes to such notice.

(2) Shall provide the CHPPM with any changes in, or revocation of, permission by individual to use or disclose PHI, is such changes affect the CHPPM's permitted or required uses and disclosures.

(3) Shall notify the CHPPM of any restriction to the use or disclosure of PHI that FBI has agreed to in

accordance with 45 CFR 164.522.

e. A breach of this clause by the FBI or CHPPM may be ground to terminate the agreement in accordance

with termination provisions contained herein.

f. Any ambiguity in this clause shall be resolve in favor of a meaning that permits the Government to comply with the Health and Human Services Final HIPAA Privacy and Security Rules.

g. The current NATs who agree to participate in this examination of injury data will sign a separate

consent agreement that basically says "I agree to participate in the examination of injury rates at the FBI

Academy that is being undertaken by the FBI and CHPPM. I consent to being interviewed for this

purpose and providing access to my medical and demographic information, with the understanding that


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CHPPM will deidentify the data before removing it from FBI premises, will keep any resultant data

confidential, and will only share such deidentified data with another agency or individual with the express

permission of the FBI."

VIII. Period of Agreement:

This agreement becomes binding and enters into force upon signature by both parties and for a period of

five years unless superseded or terminated. Prior notice of 180 days will be provided if the agreement is

to be suspended or terminated. Modifications will be made by mutual consent of both parties with annual

review of anticipated activity and additional funding requirements beyond the scope of activity currently

specified.

IX. Project Officers:

For FBI:

Margaret M. Grey

For DOD:

Dr. Joseph Knapik

Unit Chief, Health Care Programs Unit U.S. Army Center for Health Promotion and

FBIHQIHCPU, Rm 6344 Preventive Medicine, MCHB-TS-DI

935 Pennsylvania Avenue, NW 1570 Stark Road

Washington, DC 20535 Aberdeen Proving Ground, MD 21010

(202) 324-4976; FAX (202) 324-2923 (410) 436-1328; FAX (410) 436-5449

[email protected] [email protected]

X. Funding:

The FBI shall provide to CHPPM $65,678 to cover the costs of obtaining the data, analyzing the data, and

preparing the final report and briefing, as detailed in Department of Defense Form 1144 as an attachment.

Additional funding for continuation of epidemiology services following the initial analysis of historical

data will be based upon an updated estimation of the cost of services and by mutual agreement.

XI. Billing Instructions:

The FBI will send payment via direct fund cite to: USACHPPM ATTN: MCHB-TS-DI 1570 Stark Road

Aberdeen Proving Ground, MD 210I0

XII. Approvals:

Federal Bureau of Investigation:

Walter Meslar

Contracting Officer, Finance Division

Date: 21 January 2009


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Donald Packham

Executive Assistant Director Human Resources Branch

Date: 29 January 2009

US Army Center for Health Promotion and Preventive Medicine:

Steven Brewster

LTC(P), MC

Director, Epidemiology & Disease Surveillance

Date: 15 December 2008


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APPENDIX C.

Lifestyle Questionnaire

PRIVACY ACT STATEMENT – HEALTH CARE RECORDS, FITNESS TEST SCORES, AND QUESTIONNAIRE

1. AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER

Public Law 104-191, Section 1178; Executive Order 9397; Section 8103, Title 5, United States Code

2. PRINCIPLE PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED

This form provides you the advice required by the Privacy Act of 1974. Your personal information will facilitate tracking the

health, fitness, and functional status of Federal Bureau Of Investigation (FBI) New Agent Trainees with regard to injuries. The

information you agree to provide is your health records and fitness test scores during the time you serve as a New Agent Trainee.

Your Social Security Number (SSN) is required to retrieve your health records and physical fitness test scores and link these data.

A questionnaire will be administered to aid in determining how lifestyle factors affect the health of New Agent Trainees.

3. ROUTINE USES

The primary use of this information is to improve the health and fitness of FBI New Agent Trainees. Your health records, fitness

test scores, and questionnaire responses will be included in a database that contains the same information for all New Agent

Trainees. The only personnel having access to this information will be the public health officials who analyze the information.

The information will not be disclosed to any other person or agency (other than the FBI which already has these data). You will

not be personally identified in any report or by another other method since the topic of interest is the health and fitness of the

New Agent Trainee population, not the health and fitness of any single individual.

The database created with the information you provide will identify current level of fitness, current injury trends, and factors that

put New Agent Trainees at risk of injury. The database will allow tracking of fitness, injury trends, and injury risk factors over

time. The results from analysis of these data will be used to make recommendations to decision makers regarding programs and

policies that might improve fitness and reduce the incidence of injury among New Agent Trainees. The information will also be

used to evaluate the effectiveness of those recommendations when implemented.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION

Disclosure of the requested information is voluntary. By disclosing the information you agree to participate in the examination of

injury rates at the FBI Academy, consent to being interviewed for this purpose and consent to provide access to your medical and

demographic information. The information will be deidentified, will be kept confidential, and the deidentified data will be

shared with another agency or individual only with the express permission of the FBI. If you do not disclose the information you

will not be included in the database and you will not participate in the project designed to reduce injuries, identify risk factors and

improve the health and fitness of New Agent Trainees.

SIGNATURE OF PARTICIPANT

SSN OF PARTICIPANT DATE


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FBI Training & Musculoskeletal Injuries: New Agent Trainee Survey

In this questionnaire, you will be asked about yourself and your lifestyle.

Please answer each question to the best of your ability.

Background Details

1. Today’s date: |___|___| / |___|___| / |___|___|___|___|

Month Day Year 2. What is the number of your NAT class? __________________________________________

3. What is your name? __________________________________________

Last name, First name, Middle initial

4. What is your social security number? |___|___|___|–|___|___|–|___|___|___|___|

5. What is your birth date? |___|___| / |___|___| / |___|___|___|___| Month Day Year

6. Are you… 0 Male

1 Female

7. What is your Height? |___| feet |___| |___| inches

8. What is your Weight? |___| |___| |___| pounds

Tobacco Use

9. Have you smoked at least 100 cigarettes in your life? (100 cigarettes = 5 packs)

1 YES

0 NO 10. About how old were you when you smoked a whole cigarette for the first time?

(If you have never smoked a whole cigarette, write 00)

|___|___| years old 11. During the past 30 days, on how many days did you smoke a cigarette?

(If you have not smoked in the last 30 days, write 00)

|___|___| days 12. During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day on average?

(If you have not smoked in the last 30 days, write 00)

|___|___| cigarettes


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13. If you used to smoke cigarettes and quit, how many months or years ago did you quit?

(If you have never smoked or are currently smoking, write 00)

|___|___| months OR |___|___| years 14. If you are currently smoking, how many years have you been smoking?

(If you are not currently smoking, write 00) |___|___| years

15. During the past 30 days, on how many days did you use smokeless tobacco (chewing, snuffing, pinching, etc)?

(If you have not used smokeless tobacco in the last 30 days, write 00)

___|___ days

16. During the past 30 days, on the days you used smokeless tobacco, how many cans, pouches, or plugs did you use per day, on average?

(If you have not used smokeless tobacco in the last 30 days, write 0)

____ cans, pouches, or plugs

17. If you used to use smokeless tobacco and quit, how many months or years ago did you quit? (If you have never used smokeless tobacco or are currently using, write 00)

|___|___| months OR |___|___| years

18. If you are currently using smokeless tobacco, how many years have you been using smokeless tobacco?

(If you are not currently using smokeless tobacco, write 00)

|___|___| years

Physical Activity

19. Compared with others your same age and sex, how would you rate yourself on the amount of physical activity you performed before entering New Agent Training?

1 Much less active

2 Somewhat less active

3 About the same

4 Somewhat more active

5 Much more active

20. In the 2-month period before New Agent Training, how many times per week on average, did you


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perform vigorous aerobic exercise (such as running, jogging, cycling, etc.)?

0 Never

1 Less than 1 time per week

2 1 time per week

3 2 times per week

4 3 times per week

5 4 times per week

6 5 times per week

7 6 times per week

8 7 or more times per week 21. When you performed vigorous aerobic activity in the 2 months before New Agent Training, what was the average amount of time that you exercised during each session?

0 None, did not do aerobic exercise

1 1–15 minutes

2 16–30 minutes

3 31–45 minutes

4 46–60 minutes

5 61–75 minutes

6 76–90 minutes

7 More than 90 minutes 22. In the 2 months before New Agent Training, how many times per week, on average, did you do weight training (such as free weights, universal, nautilus, etc.)?

0 Never


2 1 time per week

3 2 times per week

4 3 times per week

5 4 times per week

6 5 times per week

7 6 times per week

8 7 or more times per week 23. When you performed weight training in the 2 months before New Agent Training, what was the


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average amount of time that you trained during each session?

0 None, did not do weight training

1 1–15 minutes

2 16–30 minutes

3 31–45 minutes

4 46–60 minutes

5 61–75 minutes

6 76–90 minutes

7 More than 90 minutes 24. In the 2 months before New Agent Training, how many times per week, on average, did you play sports?

0 Never


2 1 time per week

3 2 times per week

4 3 times per week

5 4 times per week

6 5 times per week

7 6 times per week

8 7 or more times per week 25. When you played sports in the 2 months before New Agent Training, what was the average amount of time that you played each time?

0 None, did not play sports

1 1–15 minutes

2 16–30 minutes

3 31–45 minutes

4 46–60 minutes

5 61–75 minutes

6 76–90 minutes

7 More than 90 minutes


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Physical Fitness

26. Rate your physical fitness just before entering New Agent Training on each of the following, compared with others of your age and sex:

Far Less Less Than Greater Than Far Greater Than Average Average Average Average Than Average

Endurance

Sprint Speed

Strength

Flexibility

Push-Ups

Sit-Ups

Body Fat

Injury History

27. Prior to New Agent Training, did you ever injure bone, muscle, tendon, ligaments, and/or cartilage in one or both of your lower limbs (feet, ankles, legs, knees, or hips)?

1 YES

0 NO 28. Did any of these lower limb injuries prevent you from participating in your normal physical activities for at least one week?

7 Does not apply, never had lower limb injury

1 YES

0 NO 29. Following these lower limb injuries, were you able to eventually return to 100% of your normal physical activities?

7 Does not apply, never had lower limb injury

1 YES

0 NO


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30. Prior to New Agent Training, did you ever injure bone, muscle, tendon, ligaments, and/or cartilage in one or both of your upper limbs (hands, wrist, arms, elbows, or shoulders)?

1 YES

0 NO

31. Did any of these upper limb injuries prevent you from participating in your normal physical activities for at least one week?

7 Does not apply, never had upper limb injury

1 YES

0 NO

32. Following these upper limb injuries, were you able to eventually return to 100% of your normal physical activities?

7 Does not apply, never had upper limb injury

1 YES

0 NO

33. In the year prior to New Agent Training, did you have foot pain that caused you to limit your daily activity some of the time?

1 YES

0 NO

34. In the year prior to New Agent Training, did you have knee pain that caused you to limit your daily activity some of the time?

1 YES

0 NO

35. In the year prior to New Agent Training, did you have back pain that caused you to limit your daily activity some of the time?

1 YES

0 NO

If you are a man, stop here. Thank you for completing this questionnaire.

If you are a woman, complete the questions on the next page.


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Female Questions

36. At what age did you start to menstruate? (If you have not had a menstrual period, write 00)

|___|___| years

37. Over the last 12 months, how many menstrual periods did you have? (If you have not had a menstrual period, write 00)

|___|___| menstrual periods

38. During the last 12 months, have you missed 6 or more months in a row between menstrual cycles?

7 N/A, I never had a menstrual period

1 Yes, I missed 6 months or more in a row between menstrual cycles

0 No, I did not miss 6 or more months in a row between menstrual cycles

39. In the last 12 months, have you taken birth control pills?

1 YES

0 NO

40. In the last 12 months, have you taken any hormonal therapy other than birth control pills?

1 YES

0 NO 41. If you have ever been pregnant, how many months or years ago were you last pregnant? (If you have never been pregnant, write 00)

|___|___| months OR |___|___| years

Thank you for completing this questionnaire


D-1

APPENDIX D.

New Agent Trainee Profile Form


E-1

Appendix E. Standard Form 88 (Report of Medical Examination)


E-2


F-1

APPENDIX F.

MEDICAL RECORDS DATABASE DESIGN AND CODING

INJURY DATA – Enter the following for each medical visit for injury:

Date of Visit: (DD-MMM-YY, e.g. 12-JAN-09).

Follow-up?: “No” indicates a first visit for this condition; “yes” indicates a follow-up visit (subject was

seen previously for this condition). Default value is “no” (0).

0=no

1=yes

8=unknown

Associated Training Activity: Training activity associated with the injury (if any). Sometimes the

training activity is not listed for the initial visit but is listed for a follow-up visit.

Default value is “not applicable” (97).

Physical training (PT)

Sports

Defensive Tactics Training

Operational Skills Training

Firearms Training

Driver Training

Physical Fitness Testing

Case Scenario (Hogan’s Alley)

Off-Duty, Academy

Off-Duty, Not Academy

other

not applicable

unknown

Activity/Mechanism Notes: Enter a more detailed description of how the injury occurred. Record

exactly what is in the medical record.

Diagnosis: Choose one of the following diagnoses from the drop box. Default value is 0–“no visits.”

Code Abbreviation Description

Overuse

Injuries

1 STR_FX stress fracture

2 STR_RXN stress reaction

3 TND tendonitis

4 DJD degenerative joint disease

5 BURS bursitis

6 FASC fasciitis

7 RPPS retropatellar pain syndrome

8 IMP impingement

9 STRAIN_OU muscle injury, not involving joint, due to overuse

10 SPRAIN_OU joint injury due to overuse

11 PAIN_OU musculoskeletal pain due to overuse

12 OTH_OU overuse injury, other

13 SHIN_SPL shin splints

Traumatic

Injuries

14 STRAIN_TR muscle injury, not involving joint, due to a traumatic event

15 SPRAIN_TR joint injury due to a traumatic event

16 PAIN_TR musculoskeletal pain due to traumatic event


F-2

17 OTH_TI other traumatic injury

18 DISLOCN dislocation

19 DERANG joint derangement (e.g. meniscus tear)

20 FRACT Fracture

21 BLISTER Blister

22 ABRSN_LC abrasion or laceration

23 CONTSN contusion

24 CONCUSS Concussion

26 OPENWND open wound

Other Injuries 26 OTH_MS other musculoskeletal injury, not listed above

27 NEURO neurological

Environmental

Injuries

28 HEAT heat-related injury or illness (e.g., heat exhaustion, dehydration)

29 COLD cold-related injury or illness (e.g., frostbite, hypothermia)

30 BITE_IN insect bites or stings

31 BITE_AN other animal or snake bite

32 RHABDO Rhabdomyolysis

33 OTH_ENV other, environmental/toxic injury

Miscellaneous

Categories

0 NO_VISITS no visits

96 OTH_INJ other injury

97 NORMAL normal exam – nothing found

98 UNK Unknown

Diagnosis Notes: Enter a more detailed description of the diagnosis. Record exactly what is in the

medical record.

Body Side: This is typically given with the subjective or assessment portion of the SOAP.

Left

Right

Bilateral

Midline

Other

Unknown

Body part: This is typically given with the diagnosis.


1 HEAD head

2 FACE face

3 EAR ear

4 EYE eye

5 NECK neck

6 CHEST chest

7 ABDMN abdomen


16 FINGER finger

17 PELV_REG pelvic region

18 HIP hip

19 POST_THIGH posterior thigh (hamstring)

20 ANT_THIGH anterior thigh (quadriceps)

21 KNEE knee

22 CALF calf


F-3

8 UP_BACK upper back

9 LO_BACK lower back

10 SHLDR shoulder

11 ELBOW elbow

12 UP_ARM upper arm

13 LO_ARM lower arm

14 WRIST wrist

15 HAND hand

23 SHIN shin

24 ANKLE ankle

25 FOOT foot

26 TOE toe

27 MULTI multiple

96 OTH other

97 NA not applicable

98 UNK unknown

Disposition: Final outcome of the injury visit as assigned by the medical provider. If the provider issued

both a consult and limited duty, list limited duty.

Returned to duty

Limited duty (and RTD)

Quarters

Hospitalized

Consult

Other

Not applicable

Unknown

Days of Limited Duty: Enter the number of days of limited duty given to the NAT. Enter 0 if the no

days of limited duty are given (Disposition=Returned to duty). Days of limited duty are typically

found with the disposition. If limited duty is indicated, but no days are listed, enter 99 (missing).

Additional Notes: Enter miscellaneous notes on events surrounding the occurrence of the injury or

illness.


G-1

Appendix G. CA-1 Form. Federal Employee Notice of Traumatic Injury

and Claim for Continuation of Pay Compensation


G-2

epidemiological report no. 12-hf-97hrf1a-10 … · ms tanya harvin, occupational health nursing...

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